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Electronic Patient Clinical Record Configuration User Guide

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1. responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 50 The MEND exam supports the clinician in the evaluation of patients suspected of having suffered a Stroke The clinician evaluates several parameters and records them as Normal or Abnormal by clicking on the appropriate button Once completed the clinician clicks OK ortivus Nervous S m Priority Genci ve Cardi Tore TIA ovascular Incident Respiratory Pathway status Primary Gastro Survey intestinal Obs amp Gynae amp Maternity Vital Signs nin Nervous Status System History Mucci loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge shin MEND Examination S gt Test Patient ranial N Level of consciousness A Speech you can t teach at Questions age and mont Commands close eyes ke Facial Droop show teeth Visual Fields 4 quadrants Horizontal gaze side to si Motor arm drift close eye Leg drift open eyes lift e Sensory arms and legs Coordination arms and hi 12 39 Other Speech you can t teach an old dog new tricks a LTE Delete Questions age and month Commands close eyes keep them shut then open oe eas basta 0 0 Delete Visual Fields 4 quadrants Horizontal gaze side to side o Limbs Motor arm drift close eyes hold out arms
2. i BU Fracture F Dislocation DL Amputation AM Wound WO Delete 7 i ESI she committed South Western Ambulance Service NHS NHS Foundation Trust 4 3 27 The Body Map screens enable the user to annotate a body map either from a view of the Front of the patient or from a view of the Back of the patient This identifies the position on the body of Pain Swelling Contusion or Numbness 4 3 28 The clinician clicks on the relevant button then on the body to show location This opens up a separate data entry field for the capture of information relating to that Assessment gt Test Patient iN Medical Assessment Priority Condition History of Condition Incident baa nation Major Trauma Body Map Vital Signs Status History Secondary Other Maps Exclusion Contrain dication Swelling S Contusion C Numbness Nu Survey Drug Inter vention Treatment Discharge responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 3 28 The Body Map screens enable the user to annotate a body map either from a view of the Front of the patient or from a view of the Back of the patient This identifies the position on the body of an intervention relating to the placement of Intra Venous Cannula Intra Osseous or Arterial Tourniquet 4 3 29 The clinician clicks on the relevant button then on the body to show locatio
3. responsive committeg effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 56 The Other Intervention field allows the clinician to document any other intervention not recorded elsewhere that has been applied in free text format gt Test Patient k Other Intervention lt lt Priority Immobi lisation Incident Muscu loskeletal Primary Burn in s vention z urvey Other Intervention Free Text Wound Care Vital Signs Hae morrhage Status Control Hemi Respiratory Secondary Critical Survey Care Throm Drug Inter bolysis vention Cathete risation Other Inter _ vention Exclusion Discharge Contrain _dication Ww responsive committed NHS Foundation Trust pont South Western Ambulance Service hz A 4 8 57 The Exclusion Contra indication field allows the clinician to document any other deviation from clinical guidelines and or any contraindication to treatment not recorded elsewhere that has been provided in free text format gt Test Patient y Edision ContrasdicxGon Priority Sooo RoOOOoooqoqoq4eo2NMNSsosOsooONwsNoOoOqNOqNouqNou q OONNGNHSoHoooooooq4q4N00N000O 0 Immobi lisation Incident Muscu loskeletal Primary Burn in S vention Ra Ss E urey Exclusion Contraindication Clinical Intervention Wound Care Vital Signs TE morrhage History Respiratory Secondary Critical Survey Care Throm
4. cpiriritted NHS Foundation Trust a aN South Western Ambulance Service hz 4 2 Primary Tab Incident 4 2 1 Data captured within the Details Screen relate to the information provided by the caller into the 999 system Data will be captured within the Computer Aided Dispatch system CAD this data will then be auto populated within the fields shown 4 2 2 Any data field that is pre populated can be over ridden by the clinician 4 2 3 Auto population is achieved by clicking on the Incident Number button and selecting the appropriate incident that has been dispatched to the vehicle 4 2 4 Should the clinician commence ePCR completion whilst out of signal the clinician can continue with data entry until such time as the vehicle connects to the network At this time the clinician can click on the Incident Number button and select the appropriate incident Should any data fields that are CAD auto populated be manually entered they will be over ridden by the data entered into CAD For example if the Clinical Hub have entered the patient as John Jones and the clinician has subsequently found the patient to be June Jones this will be over ridden by CAD push and will need to be re entered Test Patient Details Priori Details ae Incident Date Patient i eE Incident Number Crew1 Name Times Primary a Survey i Crew2 PIN Vital Signs i i Crew2 Name Status i Crew3 PIN History Secondary i Crew3 Na
5. Exami nation WIG Estimated Impact Speed mph Trauma Body Map Vital Signs Status Exclusion History Contrain dication Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective PA South Western Ambulance Service h z 4J NHS Foundation Trust 4 3 41 In order to allow the clinician to free hand draw a diagram or pictorial representation of the incident site or position of vehicles on the road etc a large free text drawing box is provided 4 3 42 The clinician clicks on Change and then uses the stylus provided to draw onto the screen the image they require gt Test Patient AEri Medical Assessment Priority Condition History of Condition Incident Bunn nation Major Trauma Body Map Vital Signs Status Exclusion History Contrain dication Secondary Survey Drug Inter vention Treatment Discharge responsive committed Oe South Western Ambulance Service NHS y L325 NHS Foundation Trust 4 3 43 A Exclusion Contra indication box is provided should the clinician wish to document any deviation from local or national guidelines at this point in the patient assessment This is a free text format and the box expands as data is entered Presenting Priority Condition History of Condition Incident Exami nation Major Trauma Body Map Vital Signs Other Maps Status History Sec
6. Hae me bins Secondary morrhage a a Survey Control Time i 19 12 2014 13 07 Drug Inter Respiratory 12 mn vention Critical Care Throm bolysis Cathete Discharge risation ON 3 Ne eT i WwW responsive committed South Western Ambulance Service NHS NHS Foundation Trust device was applied 4 8 28 The Extrication screen simply captures the use and the time the extrication ortivus ie Priority Cardiac Incident Airway Primary Survey Muscu loskeletal Vital Signs Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter vention Respiratory Critical Care Throm bolysis Cathete Discharge risation Orb S Ts v Advanced Cervical Collar Pelvic Splint Vacuum Splint Rescure Board Scoop Stretcher Vacuum Mattress Traction Splint Extrication Other Sve cp ru nitted NHS Foundation Trust pe A South Western Ambulance Service h z 54 4 8 29 The Other screen simply allows the clinician to document in free text format any Other Immobilisation used but not documented elsewhere ortivus Test Patient a __ Immobilisation Priority Cardiac Cervical Collar Pelvic Splint s a w y a f Incident Adana Vacuum Mattress Vacuum Splint Traction Splint Extrication Other aU AE Other Immobilisation Immobi Primary lisation Survey Muscu loskeletal Vit
7. Survey Drug Inter vention Treatment Discharge committed effective gt South Western Ambulance Service hA l te S a ia NHS Foundation Trust Z Ve Se E 4 2 20 All timings related to the patient engagement are directly fed from CAD with the exception of Time at Patient Side this must be manually entered 4 2 21 Any patient incident time auto populated via CAD can be overridden by the clinician ortivus ee Details Priority Primary Fo B FQ i Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge oo rier Lil 4 3 4 3 1 4 3 2 4 3 3 4 3 4 4 3 5 Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge South Western Ambulance Service NHS NAS Foundation Trust Primary Tab Primary Survey The Presenting Condition Category drop down list accessed by clicking the black triangle presents the clinician with a number of clinical categories such as cardiac or trauma Once selected a second drop down will appear which provides a list of sub categories for example in Cardiac there is STEMI or within Trauma Leg Injury or Head Injury Open The Presenting Condition box below allows the clinician to detail in free text format anything that is pertinent to the nature of the patients complaint This free text box expands as the clinician types to allow for the co
8. Treatment Are any of the following events known to have occurred TESKA Sie committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 9 21 In order to document any and all Others present in the household at the time of the ambulance attendance data fields are provided to capture the name and relationship to the deceased These fields can be accessed by clicking New for each individual present 4 9 22 Once completed the Child Death referrals can be accessed and emailed directly to the Trust Safeguarding Team as previously described in the Referrals screen Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Final Disposition Referrals Refusal Safety Net ting Safe guarding Right Care Air Ambul ance Log S Test Patient Please supply in detail the environment that the child was found Please describe any difficulties experienced when delivering care to the Patient Please detail others present in the household V Name Relationship to Child Additional Comments Are any of the following events known to have occurred __New Change la 0 0 Delete Describe the ethnicity of the child and family carers and any racial cultural linguistic and religious identity or needs Child Death Free Text responsive committed effective South Western Ambulan
9. z ag ina Contrain vention ee dication Treatment nn 19 12 2014 12 53 Discharge bere South Western Ambulance Service h z 549 NHS Foundation Trust 4 6 83 The Falls screen enables the clinician to enter details relevant to any patient who has suffered a fall This includes data fields designed to capture the nature of the Fall whether this has impacted on the patients ability to Weight Bear and Mobilise 4 6 84 The Falls screen also captures information relevant to the Falls Risk Assessment ortivus gt lest Patient 12 53 mi eee Musculoskeletal i Guide lt lt Priority v Bi Cardi ovascular Incident Respiratory Primary Gastro Survey intestinal Obs amp Vital Signs Gynae amp Is Patient weight bearing Maternity Nervous Status System History Patient Mobilisation Is Patient able to mobilise without assistance Muscu loskeletal Mental Is Patient able to mobilise with assistance Health Drug Inter oc Mobilisation Free Text o Contrain ven dication Falls Risk Assessment Trea Has Patient fallen in past 12 months Discharge If Yes how many Does Patient take four or more medications ner dav responsive committed effective 4 6 85 In many areas Falls teams will have referral processes in place to support South Western Ambulance Service NHS NHS Foundation Trust patients and put in place measures to prevent
10. Drug Inter vention Discharge The Defibrillation screen captures information relating to the Initial Arrest Rhythm via drop down list and further details relating to the use of defibrillation including number of shocks and associated timings S gt lest Patient Cardiac CPR Ventilation Defi ROSC Re i i it Pacing Advanced Airway Immobi lisation Muscu loskeletal en choi dale lat Burn Inter vention Seaver ist shock delivered by Care kaai Shock delivered by Other morrhage Control Total number shocks Respiratory Critical Care Throm bolysis Cathete risation Oth Tne Fi WwW responsive committed 4 8 6 Priority Incident Primary Survey Vital Signs f Status History Secondary Survey Drug Inter vention Discharge Cardiac South Western Ambulance Service NHS NHS Foundation Trust The RoSC or Return of Spontaneous Circulation screen allows the clinician to enter whether RoSC has been achieved and whether it was subsequently lost or regained An additional Free Text field is provided to capture any information relevant to the loss or capture of RoSC outside of initial timings The clinician clicks on New to open the RoSC timings screen Test Patient Pacing Advanced Airway Immobi lisation To Change Muscu loskeletal ROSC Time ae ee ROSC Time Lost Maa a 0 0 Burn Inter vention Wound Ca
11. Drug Inter vention Treatment Discharge box General Cardi ovascular f Respiratory Gastro intestinal Obs amp Gynae amp Maternity i Muscu loskeletal Mental Health Exclusion Contrain dication stroke TIA Cranial Nerves Vislial Sensory TLOC Convulsions Headache Other oo rier Lil South Western Ambulance Service NHS NHS Foundation Trust 4 6 56 The clinician reviews each Cranial Nerve in turn and enters either a finding of Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Normal or Abnormal as indicated Once all Cranial Nerves have been assessed and recorded the clinician clicks Ok General Cardi Stroke ovascular F Respiratory Gastro intestinal Obs amp Gynae amp Maternity Trochlear nervi Muscu loskeletal Mental Health sO A Glossopnaryngi Contrain dication Yaw South Western Ambulance Service hz IEN NHS Foundation Trust 4 6 57 The clinician can enter details of an assessment of the patients Visual status by clicking the New button ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Elia Muscu loskeletal Mental Health Exclusion Contrain dication S
12. Electronic Patient Clinical Record Configuration User Guide Version 1 0 January 2015 South Western Ambulance Service NHS NHS Foundation Trust Contents Introduction Data Entry Drop downs Checklists White Finger Symbol Multiple assessments Fields New Delete Change Time Fields Free Text Main Menu Primary Tab Incident Primary Tab Primary Survey Primary Tab Vital Signs Primary Tab Status History Primary Tab Secondary Survey Primary Tab Drug Intervention Primary Tab Treatment Primary Tab Discharge 1 2 1 3 1 4 To South Western Ambulance Service NHS NAS Foundation Trust Introduction In line with a government initiative to develop a paper free NHS the Trust has been working on the development of an electronic Patient Clinical Record ePCR system fit for a modern 21st century ambulance service The ePCR has been created in partnership with Ortivus who is a leading supplier of mobile solutions for modern emergency medical care The solution aims to eradicate paper based data collection enhance the clinical decision making process and support the provision of the Right Care in the Right Place at the Right Time The system in essence did not exist prior to contract signature and has therefore been designed from the ground up by the small but very dedicated project team in SWASFT Using a structured model of examination and assessment the software is con
13. Gynae amp ns ol Maternity Pathway status ei iin Pain in the Malleolar Zone 0 0 Nervous System Boney tenderness in posterior edge of Lateral albia Malleolus Muscu H loskeletal Boney tenderness in posterior edge of Medial Malleolus M a a Unable to weight bear 4 steps i Pathway type E Exclusion Contrain Comment dication az 4 Pathway status 19 12 2014 12 50 D 0 0 Vv OK x ancal Delete Comment Change Dathwaw tuna responsive committed g South Western Ambulance Service NHS NHS Foundation Trust 4 6 79 The Foot Assessment provides the clinician with a series of questions each Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge created to highlight areas of clinical concern A Yes for any of the questions would indicate that an x ray may be required to rule out boney injury An additional free text field is available under Comment to capture any other findings not captured elsewhere Test Patient Musculoskeletal Guide i Spine Assessment General Cardi ovascular Lower Leg Assessmen Soft Tissue Assessment Ankle Assessment Respiratory Pathway type Gastro intestinal Obs amp Gynae amp Maternity Comment Pathway status Nervous Pain in the Malleolar Zone System A gt s a ae lt EO gt Vki ea a oe ee Boney tenderness in the
14. Discharge ovascular Gastro in determining whether any collapse is suggestive of TLoC or has a more sinister aetiology Should all questions be answered Yes the risk of serious aetiology without other indications is considered low Any additional information not captured elsewhere can be recorded within the Comment free text field lest Patient erate Nervous System Cardi Ernyo f 2 nia Nanioc Wie 3 Clinical pathways ii Oo eon Pathway type Were The Patients Symptoms Obs amp Comment Gynae amp Maternity Pathway status Transient Nervous Rapid Onset eae a sale Short Duration Delete Muscu a Ss Van Reanri syncope Spontaneous Recovery Y Mental al Any Pallor With Episode Yes No New Hea Pathway type Does Patient Remember Falling Down Exclusion JYP 9 i lun Snes uO eelu Comment Comment EA CA dicata Pathway status ae katis Respiratory Change Change 19 12 2014 12 45 0 0 Delete Syncope Free Text responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 65 On selecting the Syncope assessment the clinician will be provided with a Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Gastro number of questions which support them in determining whether any collapse is Suggestive of Syncope or has a more sinister aetiology Should all
15. Priority Cardiac Incident Advanced New Airway annan prirni Immobi Location of Dislocation Change Survey SU Management Muscu lt gt A loskeletal Outcome Vital Signs Comment 0 0 vention Delete Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter Respiratory ven om Critical Care Throm bolysis Cathete Discharge risation LON 5 bo Ti te Musculoskeletal EZA South Western Ambulance Service NHS NHS Foundation Trust Ssporishyre committed South Western Ambulance Service NHS NHS Foundation Trust 4 8 32 Once the New button has been clicked within the Fracture screen the box as below appears This enables the clinician to document in free text format the Location of Fracture the Management of the that fracture the Outcome which should include details regarding distal perfusion and distal pulses and any further relevant information such as complications and exclusions within the Comment field gt Test Patient Priority Cardiac Incident Advanced New Airway Senne Location of Fracture Fracture Primary ee Survey Ed Management Location of Fracture Muscu lt gt loskeletal Outcome no ao 0 0 apices Comment vention Status Wound History Care Change Vital Signs Delete Hae Secondary morrhage Survey Control Drug Inter Res vention 19 12 2014 13 10 Critical Care Throm bolysis Cathete D
16. Priority Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge format the positioning of patients and damage to a series of vehicles at a Road Traffic Collision gt Test Patient Biol Medical Assessment ess Condition History of gt a 5 sn ei Soe ey a C J gt ee x Condition Exami nation Major Trauma tion of Patient Pot DA Exclusion FA Contrain dication Delete 7 responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 3 33 The Position of Patient and or Fatality can be entered on to the car by clicking on the appropriate box and then on to the position on the car 4 3 34 In order to document the damage caused to the vehicle and the Direction of Priority Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge Impact the clinician clicks on Damaged Area and then on to the point of impact on the vehicle the direction through which that impact occurs can be annotated using the available arrows lest Patient i Medical Assessment Condition History of Condition Exami nation Major Trauma Pos Front passenger Danae es CS Pos Hood Body Map Damaged Area DA User NHSD david partla Damaged Area User Time 19 12 2014 11 58 Time 19 12 2014 11 58 22 Other Maps Direc
17. South Western Ambulance Service NHS NHS Foundation Trust 4 8 18 The Immobilisation screen has multiple tertiary tabs all used to capture data relevant to specific immobilisation techniques and or equipment 4 8 19 The Cervical Collar screen allows the clinician to document the Application of a collar and the relevant timings The removal or loosening of a collar is now supported when clinically appropriate so an additional free text field is provided to capture the Rationale behind this decision Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge S gt Test Patient ___ immobilisation Cardiac Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation aetna iis 4 Vacuum Mattress Vacuum Splin Cervical Collar Pelvic Splint responsive committed ae South Western Ambulance Service hz NHS Foundation Trust 4 8 20 The Pelvic Splint screen provides information to show the application of the pelvic splint and associated Time Test Patient ortivus N ____ Immobilisation Priority Cardiac Vacuum Mattress Vacuum Splin Traction Splint Cervical Collar Pelvic Splint Rescure Boal Incident Advanced i ASM Pelvic Splint Applied Primary Immobi Y es N o lisation mea Pelvic
18. TEN NHS Foundation Trust 4 8 26 The Traction Splint screen allows for the capture of multiple Traction Splints in order to access data fields the clinician clicks the New button ortivus ie Priority Cardiac Cervical Collar Pelvic Splint Rescure Board Scoop Stretcher Incident EEEE Vacuum Mattress Vacuum Splint Traction Splint Extrication Other Airway 7 Primary Survey Muscu loskeletal Vital Signs Burn Inter vention Status Wound oe me History Care Hae Secondary morrhage Survey Control Drug Inter espa vention wae ou Critical Care Throm bolysis Cathete Discharge risation Othar Lutar v coynnritted Breas South Western Ambulance Service h z A NHS Foundation Trust 4 8 27 The Traction Splint screen will appear as below the clinician can then provide details for the limb upon which traction has been applied by clicking the down arrow The screen also enables the clinician to confirm that post traction whether a Distal Pulse was present gt Test Patient R __ Immobilisation Priority Cardiac Cervical Collar Pelvic Splint cee erT i r Incident Advanced Vacuum Mattress acuum Splin Traction Splint Extrication Other Airway eee immobi Vaw Survey lisation Traction Splint Applied Traction Splint Muscu loskeletal eRe Distal Pulse Time Traction Splint Applied Vital Signs vention Status i Wound History Care Time Distal Pulse
19. Test Patient Allergies Medications Priority Medi Current Regular Medication cations Medication Past Med LEESI Free Text Primary Last Oral Survey Intake eam Medication Compliance Vital Signs 280 ee el Medication Comments Status Alcohol Drugs Tetanus Cover Secondary _ Survey Incident Drug Inter vention Treatment Discharge responsive commited effective South Western Ambulance Service hz A NHS Foundation Trust 4 5 9 Once the white finger symbol is clicked the screen below is displayed This enables the clinician to select medications that the patient is currently prescribed from an alphabetical list An additional Search functionality is provided to support the clinician in finding the appropriate medication 4 5 10 Once the medication is found the clinician highlights the appropriate medication and clicks Add this enters the medication Multiple selections can be made at this point Once all medications have been selected the clinician clicks on Ok ortivus Test Patient Medication Aciclovir es Acrivastine Search Alendronic acid Alfacalcidol Alfuzosin Allopurinol Almotriptan re 9 Amiloride Aminophylline Amiodarone w Remove v OK Q Cancel responsive committed eTectve South Western Ambulance Service NHS NHS Foundation Trust 4 5 11 The Past Medical
20. cojnrited EA South Western Ambulance Service LYA TPA NHS Foundation Trust 4 3 18 Should a New Disability Assessment be required the screen below will be displayed This enables the clinician to document the assessment of the patients conscious level their GCS and a FAST test 4 3 19 The GCS provides the ability to click Normal for any patient who has a GCS of 15 or for the clinician to click on Change to review the Eye Voice and Motor scores individually This also supports a GCS for both Adult and Child 4 3 20 Most data entered within this screen is via drop down menus however some free text is provided to capture data not felt to be relevant to any specific field ortivus Test Patient D Disability AVPU Oo pa a Eyes Verbal Motor Total Cha nge Normal Arm Leg Drift Yes No Unable Affected Side Arm Leg Left Right Speech Yes No Unable Unable to Complete Yes No Free Text 19 12 2014 11 54 South Western Ambulance Service NHS NHS Foundation Trust 4 3 21 The Major Trauma Screen provides the clinician with a drop down menu to select the Mechanism of Injury whether this be from a RTC Road Traffic Collision or from a Fall 4 3 22 This screen also requires the clinician to confirm whether an ATMIST pre alert has been provided to the receiving hospital and if so at what time that ATMIST occurred Presenting Major Trauma Priority i a o OOOO Has ATMIST been
21. 1 1 Rational Absent Relations Organised Loneliness Determination Total Is Patient being conveyed under Mental Health Act 1 0 1 1 8 No Change Norma If Yes under which Section of the MHA are they being conveyed Suicide or Self Harm Risk X High risk Is Patient being restrained Free Text Does patient have clinical diagnosis of Mental Health Condition Yes No i Unknown Niclas Mental Health Condition Free Text Yes If Yes is Patient being conveyed to Place of Safety Yes No ESA SVE committed effective Appr South Western Ambulance Service NHS NHS Foundation Trust 4 6 91 The Exclusion Contraindication screen enables the clinician to enter details Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge of any deviation from guidelines or contraindication in free text format gt Test Patient General Exclusion Contraindication Cardi ovascular Respiratory Gastro intestinal Exclusion Contraindication Secondary Survey Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication responsive committed South Western Ambulance Service NHS ifs ANA ae NHS Foundation Trust 4 7 Primary Tab Drug Intervention 4 7 1 Administered Pre Ambulance 4 7 2 The Administered Pre Ambulance screen enables the clinician to enter details of an
22. Mental Health Exclusion Contrain dication Diarrhoea Constipation 19 12 2014 12 34 G JE 3 cance oo mn om mm m mn co an aem mm am am e m om response committed effective South Western Ambulance Service NHS NHS Foundation Trust Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge ovascular 4 6 40 For Emergency Care Practitioners and those able to perform Urinalysis this functionality is included with the configuration As other assessments Urinalysis results can be entered by clicking the New button Any additional information not covered within the generalised Urinary Assessment or Urinalysis can be entered in the Urine Free Text field Test Patient fer ae Gastro intestinal SSO Cardi Urgency Poor Flow Respiratory Dribbling Gastro l intestinal Nocturia Obs amp Supra pubic tenderness Gynae amp Matemity Date of Last Catheter Change Nervous System Urinalysis Positive For Muscu z New loskeletal aaa eian Mental Nitrite Health Leukocytes Exclusion lt gt pe Protein kans came ontrain dication Glucose 0 0 Change Ketones Delete Bilirubin Blood Urine Free Text resporishye committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 41 Details of the Urinalysis assessment can be entered into the eP
23. Number Applied seeur EA morrhage Survey Control Dressing Time Respiratory Vital Signs Pressure Dressing Drug Inter ven Critical Care Throm bolysis Cathete Discharge risation LN 5 No Ten tn Ww resp i Sse 1 committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 42 The Chest Seal screen simply allows the clinician to document the number of chest seals applied and the Time of application ortivus an Priority Chest Seal Chest Decompression Finger Thoracostomy Cardiac Incident Advanced Immobi Primary eS x lisation Survey Muscu loskeletal Vital Signs Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter vention ae Critical Care Throm bolysis Cathete Discharge risation m N E v connate South Western Ambulance Service NHS NHS Foundation Trust 4 8 43 The Chest Decompression screen enables the clinician to document the attempts at Chest Decompression This captures whether this is the primary or secondary attempt whether the intervention has been Successful and the Location of the needle chest decompression 4 8 44 Additional free text format fields are provided to capture the Indication the Technique Equipment Used and any Complications experienced These fields assist in understanding the thought processes and decision making processes and a
24. Patients a E Y aaa OF Guidelines D Web browser i i Control Panel di o Open Incident 3 3 The bottom right hand of the screen shows information relating to current battery status connecting to VSM access to on screen keyboard and current log on status By clicking on the green battery symbol you will see a display showing current Battery life The VSM monitoring device icon when present means that the ePCR is not currently paired with a VSM In the image above no VSM icon is present this means the ePCR is currently paired to a VSM monitoring device 3 4 The Padlock icon shows whether the user is logged on to the system Red denotes not logged on but in signal orange denotes not logged on but out of signal so this cannot be achieved and green denotes logged on 3 5 To log on the user either clicks on the padlock icon or on the login button on the main menu A Log in box will appear so the user can enter their normal trust user name and password 3 6 Ifyou have difficulty logging on it may be that your Password has expired please ensure that you keep your password up to date when accessing your HA South Western Ambulance Service hz A ff lt lt NHS Foundation Trust emails or using a trust computer you will receive reminders in advance of any password change so please ensure you change it to prevent difficulties accessing the ePCR ortivus 13 59 MobiMed Smart User name fir stname lastna
25. Scale This is useful in particular for assessing the pain of patients with dementia The clinician reviews the questions selecting the appropriate answers The tool will then display the appropriate level of pain based on the answers provided Test Patient General General EJ Guide lt lt 19 12 2014 12 14 Change es sales 2 S 0 0 4 rts Delete Hurt Hu Hurts Little Bit Little More Even More Whole Lot Vocalisation Facial expression Change in body language Behavioural changes Physiological changes Physical changes Total Change responsive committed effective ERA South Western Ambulance Service hK T NHS Foundation Trust 4 6 8 The term Frail is often used without an agreed definition and is therefore subjective and open to personal interpretation The Rockwood Frailty Scale allows the clinician to select the description that best fits the patient they are assessing This then provides a standardised criteria and definition of frailty 4 6 9 Thee clinician simply reads each definition and selects the one that most closely matches the description of the patient ortivus Test Patient a General General Guide lt Priority Cardi ovascular Incident j Clinical Frailty Scale CCA Very Fit People who are robust active energetic motivated Well People who have no active disease but are less fit than These people commonly exercise they are among the category one O
26. Splint by whom Muscu loskeletal Vital Si a 190S f Burn Inter Time vention Status Wound History Care Hae Secondary morrhage Survey Control Respiratory Drug Inter ventou Critical Care Throm bolysis Cathete Discharge risation Oih arlotea SS WwW response committed effective Ai fpr r poe South Western Ambulance Service h z 549 NHS Foundation Trust 4 8 21 The Rescue Board can be used as a device to support extrication and be used in conjunction with a vacuum mattress and also as an immobilisation device in its own right This screen allows the clinician to document its use in both roles gt Test Patient a C Immobilisation Priority Cardiac Vacuum Mattress Vacuum Splin Incidental Advanced Cervical Collar Pelvic Splint Airway Immobi Primary lisation Survey Muscu loskeletal Vital Signs g Burn Inter vention Status i Wound History Care Hae Secondary morrhage Survey Control Drug Inter Resp vention Critical Care Throm bolysis Cathete Discharge risation Oth Tn i v responsive committed Ai fpr LoOT South Western Ambulance Service hz AJ NHS Foundation Trust 4 8 22 The Scoop Stretcher can be used as a device to support extrication and be used in conjunction with a vacuum mattress and also as an immobilisation device in its own right This screen allows the clinician to document its
27. Successful OP NP Supra Glottic ETT Needle Cric ho VOS Chest Auscultated SOR EtCo2 Checked nites Intervention NP Intervention Needle Cric y a Intervention Supra glottic Intervention Surgical Intervention Attempted cil Yes 19 12 2014 11 50 responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 3 14 Should a New Breathing Assessment be required the screen below will be displayed This enables the clinician to document the assessment of the patients breathing including the findings of auscultation and percussion 4 3 15 Most data entered within this screen is via drop down menus however some free text is provided to capture data not felt to be relevant to any specific field gt Test Patient B Breathing Assessment of Breathing Crackles v y v Percussion Hypo Resonant y Inspiratory or Expiratory Hyper Resonant Inspiratory Expiratory Comment annae lasas 19 12 2014 11 51 ES SWE committed g eae South Western Ambulance Service hz r an N NHS Foundation Trust 4 3 16 Should a New Circulatory Assessment be required the screen below will be displayed This enables the clinician to document the findings of their assessment of any circulatory compromise 4 3 17 Data entered within this screen is via drop down menus ortivus 19 12 2014 11 52
28. The signature field can be accessed by clicking on Change button and then the clinician uses the stylus provided to sign the appropriate box on the screen Test Patient Final Pe n B Final Disposition A Guide Priority Disposition Referrals Incident Confirmation of Destination BOOS Confirmation of Destination Division Primary Safety Net V Survey ting guarding Right Care ee eee e aceea S Q Confirm Presenting Condition Air Ambul ance Vital Signs Status History Secondary Log Sune Provisional Diagnosis Free Text Drug Inter vention Clinical Handover Accepting Clinician Name Treatment Clinical Handover Accepting Clinician Role ew Clinician Signature i responsive committed effective 4 9 9 Should there be a delay between the Clinical Handover the point at which the clinical details are provided to the accepting clinician and the Physical Handover or Patient Handover i e the point at which the patient is physically transferred from the ambulance crew to the receiving hospital allowing the ambulance clinician to return to operational duties fields are duplicated for to capture this delay ortivus lest Patient 13 18 Final ALUE Disposition Final Disposition Guide lt lt Referrals Incident Hospital Clinical Handover Time Clinical Handover is the Time at which the Patient s Clinical presentation observations and assessme
29. Visua TLOC Gonmvulsions Headache Other ovascular Incident Respiratory Primary Gastro Survey intestinal Obs amp Gynae amp Vital Si ee Maternity Nervous Status System History Masel loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge responsive committed Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge South Western Ambulance Service NHS NHS Foundation Trust 4 6 71 The Musculoskeletal screens have a number of tertiary tabs that enable the clinician to document findings associated with a detailed assessment of the patient s musculo skeletal system This includes C Spine general Assessment Lower Leg Assessment Soft Tissue Assessment and information relating to any patient who has suffered a Fall General Cardi ovascular Respiratory I Gastro intestinal Obs amp Gynae amp Maternity Nervous System Mental Health Exclusion Contrain dication Lower Leg Assessment Soft Tissue Assessment MFalls connate South Western Ambulance Service NHS NHS Foundation Trust 4 6 72 The C Spine Assessment accessed via the New button provides the Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge clinician with an electronic version of the Ca
30. committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 53 The ABCD2 score estimates risk of stroke after a TIA In order to calculate this score the clinician clicks on Change to enter the calculation tool Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi Stroke ovascular f TMA Crantal Nerves Visual ILOC Gonvulsions Headache Sensory Other Respiratory S Gastro intestinal Obs amp Gynae amp Maternity Muscu loskeletal Mental Health Exclusion Contrain dication AC SE i iA j atic C ja ota Te a Ll a E aange Normal OP O ox Cance South Western Ambulance Service NHS NHS Foundation Trust 4 6 54 The Clinician uses the ABCD2 tool to answer the questions as presented once all questions are answered the clinician clicks Ok and the screen will return to the TIA screen and display the total ABCD2 Score as below ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular gt test test 123 456 7890 Nervous System TEOG ABCD2 Score Age Patient over 60 years Duration Duration of symptoms Speech Blood pressure systolic over 140 and or No diastolic greater than 90 No asian mean Yes 0 No mI yes Diabetes
31. further falls Information captured here is used to populate the Falls Referral form and is therefore vital to complete the holistic care for the patient Data fields are available in Yes No format and there is also a Falls Risk Assessment Free Text field to capture information not provided elsewhere ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge lest Patient JAE Musculoskeletal Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication Does Patient take four or more medications per day Does Patient have diagnosis Stroke or Parkinson s Disease Does Patient have pre existing problem with balance Does Patient have difficulty rising from chair without using their arms Does Patient have pre existing diagnosis of Osteoporosis Has Patient had previous fractures Was fall related to alcohol drug abuse e e Se gt e ae e S Falls Risk Assessment Free Text response committed South Western Ambulance Service NHS ifr NHS Foundation Trust 4 6 86 The Mental Health screen allows the clinician to enter details for those patients known to have a mental health condition and for those who present with suicide and or self harm 4 6 87 Details of any diagnosed condition can be ente
32. in a free text format ore General Priority Cardi ovascular f Incident Diarrhoea Constipation Bowel Sounds Abdominal Assessment Urinary Assessment Respiratory S fine i Primary mi S Obs amp eee Gynae amp Vital Signs y Maternity Nervous Status System History Muscu loskeletal Mental Health Exclusion Drug Inter Contrai vention Siege dication Treatment Discharge connate South Western Ambulance Service hZ AJ A eee NHS Foundation Trust 4 6 33 For those able to appreciate the nature of bowel bounds and conduct an appropriate assessment The Bowel Sounds screen enables the clinician to enter details by clicking the New button ue General Priority peis Diarrhoea Constipation Bowel Sounds Abdominal Assessment Urinary Assessment ovascular f Incident Respiratory Primary Survey Obs amp Aa Gynae amp Vital Signs y i Maternity Nervous Status System History Muscu loskeletal Mental Health Exclusion Drug Inter Contate vention ae dication Treatment Discharge coynnritted South Western Ambulance Service NHS NHS Foundation Trust 4 6 34 Once clicked the following data box appears the clinician can then click on the down arrow to bring up a drop down list of Bowel Sounds and also has the option of entering additional free text ortivus Priority Incident Primary Survey Vital Signs Status History Drug I
33. of the birth water birth for example or any other information felt relevant such as the time of labour gt Test Patient z EF ide lt lt Priority AEA Obs amp Gynae and Maternity Guide SS Cardi ovascular Incident Respiratory Normal Delivery Primary Gastro Ab oad Survey intestinal ONSEN Obs amp ital Si Gynae amp Gestation at Del ks Vital Signs Matemhity ivery Wks Nervous Status System History AY loskeletal Mental Health D Exclusion rug nter Contrain vention ae dication Treatment Appearance i Pulse Rate Discharge Grimace or Response to Stimulation Activity or Muscle Tone responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 46 In order to capture the Time of Delivery and also the APGAR score of the Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge newborn a multiple time field is provided to support the occasions of both single and multiple births The clinician simply clicks on the New button to open the APGAR screen the time Of Delivery as with other time fields will be pre populated but can be adjusted by clicking the clock symbol Test Patient AEA Obs amp Gynae and Maternity Guide Cardi ai Me y paryagi roy ovascular Respiratory Gastro intestinal Obs amp Gynae amp Maternity Appearance Pul
34. renal failure or any other severe systemic illness wails nl Thrombolysis can now be administered Comment Care Throm bolysis Cathete risation 05 01 2015 16 19 v OK x Cancel n v responsive committed effective NHS Foundation Trust 4 8 54 The Catheterisation screen enables those clinicians trained and deemed competent in urinary catheterisation to document the use of this intervention The clinician can identify if this is a Primary intervention possibly to relieve acute retention Re catheterisation to remove and replace a blocked catheter or the removal and replacement of a Supra pubic catheter 4 8 55 It is important that the clinician documents the Post Insertion Urine Output and additionally should ensure any complications and the details of appropriate follow up and referral are captured within the Catheterisation Free Text field ortivus Test Patient 13 16 Ree Catheterisation Guida Priority Cardiac Indication Incident Advanced oe es Nina Type Primary Immobi Survey lisation Cati Used Muscu CORAN o aa Burn Inter vention W Status Wound Time History Care Hae Leama Sele Miele Post Insertion Urine Output mls Survey Control Vital Signs Drug Inter Sic iil Catheterisation Free Text vero Critical Care Throm bolysis Cathete Discharge risation LON 3 bo To Fn Sse South Western Ambulance Service NHS
35. the secondary survey without complication 4 3 10 Should an assessment be required the New assessment button opens up the assessment page as below 4 3 11 Should the clinician wish to conduct multiple assessments and wish to see Priority Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge previous outcomes the button opens up the previous assessments for review S Test Patient eel Examination W Condition AAAI History of Condition Exami nation Major eee No Airway Assessment Required New Body Map Change Other Maps tuo laza Exclusion 0 0 Contrain dication Delete B Breathing o Breathing Assessmen quired New Change Enes 0 0 Delete C Circulatory No Circulatory Assessment Required responsive commited effective i prone South Western Ambulance Service hz Sas Se NHS Foundation Trust 4 3 12 Should a New Airway Assessment be required the screen below will be displayed This enables the clinician to document the status of the airway and any interventions required to maintain that airway 4 3 13 Most data entered within this screen is via drop down menus however some free text is provided to capture data not felt to be relevant to any specific field gt Test Patient 6 Guidelines Intervention ETT Number of Attempts y Vocal Chords Viewed Intervention ETT
36. 0 ne PAMA incident Times Priority Time of Call for Performance Dispatch Time Time Crew Mobile At Scene lman bnan Incident Times Left Scene At Hospital Clear from Incident Time Primary Survey Patient Time of Call for Performance Vital Signs Date Time Day Month Year Hour Minute Status History Secondary Survey Drug Inter v OK x Cancel vention Treatment Discharge 2 14 Whilst as mentioned earlier drop down boxes and structured data entry is used to assist the clinician support decision making and enhance the quality of data capture However some assessments or patient information cannot be adequately captured within a structured format and require the use of Free Text format Free text in particular can be used to evidence decision making which supports any use of the individual clinical record for the purpose of complaints concerns Serious Incidents trauma review Coroners Court etc m lest Test 123 456 7890 Final ALEE Disposition Final Disposit Guide lt lt Referrals ee amp Treat Disposition Reason Patient discharged into self care Refusal a Incident D E a E k po Linked Care Episode Incident Numbe Patient discharged into care of relative carer Safe Yes Vital Signs guarding Patient self conveying Right Care MES Status Patient being conveyed by other Ambulance Resource Air Ambul History Yes Free Text Second
37. 16 box is ticked Yes and on paediatric competency if the Is the Patient Over 16 box is ticked No gt Test Patient 11 48 T s Guide lt lt Details Clinical pathways Patient Incident Times Does Patient Have Capacity Patient Under 16 Has the Patient explicitly requested that you do not involve their parents carers in assessment treatment haa Es a haa NO a decisions Have you done everything you can to persuade them to 0 0 involve their parents carers please enter Patient s ER kaoa rationale for not involving parents carers Delete Can the Patient understand the advise information they have been given a a SO Do they have sufficient maturity to understand what is involved and what the implications are Meat Sa saat Can they comprehend and retain information relating to the advise information they have been given MES alta aes NO Do they understand the consequences of having not i 2 Comment Time 19 12 2014 11 48 Cv Resa x Ror responsive i Comm itteg effective Ya South Western Ambulance Service hz TEEN NHS Foundation Trust 4 2 19 The Research tab is used only to record patients who are known to be currently enrolled in Trust Research project or in an external health research project was lest Patient E Details Priority Patient NoK GP Consent Research Incident Times Primary Survey Vital Signs Status History Secondary
38. 4 fJ Somerset 7819416 4511 mE 5 EEE B Canc el 3 9 Guidelines have been placed on the EUD to support crews in determining the most appropriate action to take to deliver care to their patient Guidelines can be accessed direct from the main menu screen and include trust Clinical Guidelines National guidelines from NICE and other clinical organisations JRCALC and other useful operational documents ortivus 5 Test Test 123 456 7890 09 26 1 Clinical Guidance 1 1 National Guidance 1 2 Patient Group Directions and Medicines Protocols 1 3 Clinical Guidelines 1 4 Clinical Notices LLAJ 1 5 Clinical Standard Operating Procedures 1 6 Medicine Standard Operating Procedures 1 7 JRCALC 2 Operational Guidance 2 1 Operational Standard Operating Procedures 3 HART CBRN Clinical Features Q Home Q Close ESSM IVe committed 5 EN South Western Ambulance Service hz 4J NHS Foundation Trust 3 10 Guidelines and other relevant documents have also been placed within the configuration These Guidelines are accessible by clicking on the Guidelines button within the ePCR Guidelines within the configuration itself are placed to be relevant to the specific subject that is being presented on the screen ortivus 5 Test Test 123 456 7890 lt a oe General Cardiovascular K Guide lt lt Priority Cardi ovascular Incident f Respiratory Si New Primary fone ECG Date amp
39. Ambulance Service NHS NHS Foundation Trust 4 8 16 Should the clinician be trained and competent in the use of needle Crichothyroidotomy intervention and wish to record this the Crichothyroidotomy screen can be used to capture this data The clinician clicks on the New button to enter the date fields Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Cardiac Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Othar Lata v Surgical Airway Crichothyroidotomy f cp rin Lil South Western Ambulance Service NHS NHS Foundation Trust 4 8 17 The Crichothyroidotomy screen has a number of data fields many of which are in free text format to capture the intervention Name of Clinician performing this and details of Rationale Technique and Complications Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Cardiac Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae LOLLL Te Control Respiratory Critical Care Throm bolysis Cathete risation Othar Lata v Surgical Airway Crichothyroidotormy iii nn nn nn nnn nnn rn nnrnnnnnnnnn nn nnn Unni we 19 12 2014 13 03 wo TT sive Io
40. CR by clicking Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge on the Yes No buttons followed by Ok General Cardi ovascular Respiratory Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication Glucose 19 12 2014 12 34 G responsive committed NHS Foundation Trust roi South Western Ambulance Service h z J 4 6 42 Information relevant to the patients Obstetric and or Gynaecological status can be entered within the Obs amp Gynae screen Data can be entered either as simple Yes No or as free text or numerical data fields Where a Number is required this should be entered using numerical inputs 1 2 3 etc 4 6 43 As with other Date Time fields the Date of Last Ectopic or any other Date field can be adjusted by clicking on the clock symbol and then using the and buttons as appropriate ortivus Test Patient 12 35 Priority AEA Obs amp Gynae and Maternity PY Guides Cardi ovascular Respiratory Is the Patient Pregnant Obs amp Gynae Incident Primary Gastro Survey eee Number Previous Pregnancies Obs amp TAE ne amp Number Previous Births Maternity Nervous Status System Number Previous Miscarriage History Mua loskeletal ETAP T pE lowe tnt Mental Health Exclusion Previous Ectopic Dre
41. Delete buttons as below The clinician clicks on the set of observations or data set requiring change deletion the set of data in this case observations will be outlined in purple The clinician can then click on Change or Delete as appropriate If change is selected the set of observations will appear for adjustment as required ortivus 5 Test Test 123 456 7890 08 53 Priority Incident Primary Survey Status History Secondary Survey Drug Inter vention Treatment Discharge 2 13 Vital Signs Vital Signs lt lt Resp Rate 20 18 iii C I al S BP Standing or Sitting or Laying Standing lucis aia Systolic BP 120 Se Diastolic BP 80 __ Delete _ BP Left or Right Left SpO2 on air 98 8 SpO2 on oxygen 98 EtCO2 6 0 60 Blood Glucose 5 0 37 1 Temperature 37 0 aa Method of Capture Tympanic PEFR 60 8001 pm 90 PEFR Patient s Norm 60 800I pm 90 er o Vital Signs Free Text and Exclusion Time Fields are identified i by the clock symbol If the clinician clicks on any blank the current time and or date will be automatically inputted Should the clinician by retrospectively entering data they can enter the correct time of assessment by clicking on the clock symbol and adjusting the subsequent date and time can then be adjusted upwards or downwards as appropriate by using the or buttons South Western Ambulance Service NHS NHS Foundation Trust 5 Test Test 123 456 789
42. Drug Inter bolysis vention Cathete risation Other Inter vention Exclusion DREG Contrain dication responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 9 Primary Tab Discharge 4 9 1 Final Disposition 4 9 2 The Final Disposition screen has two tertiary tabs to capture details of any patients who are managed without conveyance See amp Treat and any patients who are conveyed See amp Convey 4 9 3 Within See amp Treat the clinician can document the Reason for Disposition which may be that the crew have been stood down or the patient has been conveyed by another resource The clinician can also document the Linked Care Episode Incident Number this is for incidents attended earlier as an emergency response which is being managed as an Urgent incident 4 9 4 Details of the Provisional Diagnosis can be provided using the drop down arrow as below and also with the Provisional Diagnosis Free Text field which will expand as required to capture any information relevant to the Provisional Diagnosis not entered elsewhere within the ePCR 4 9 5 Details of the patients discharge can be entered using the Yes No buttons provided or the final Free Text field provided lest Patient Final Final Disposition ALEE Disposition Referrals Incident f Patient discharged into self care Refusal Primary Safety Net ii Patient discharged into care of relative carer
43. History tab is sub divided with a number of tertiary tabs these identify specific medical history relevant to one clinical area Additionally should the patient have no Past Medical History of Note the clinician can click on No as below 4 5 12 The Past Medical History tab opens with the Cardiac screen this enables Priority Incident Primary Survey Vital Signs Secondary Survey Drug Inter vention Treatment Discharge the clinician to identify any relevant history the patient may have impacting on their cardiac function For example if the patient has previously suffered an MI Myocardial Infarction the clinician can enter Yes and then select a Month Year within the Previous MI Date to identify the approximate date of the previous MI gt Test Patient NALEJ Past Medical History Guide Medi Past Medical History of Note cations Palliative Ramilial Other Last Oral Intake Last Elimi nation Infection Status Alcohol Drugs respor sve committed effective NHS Foundation Trust fi South Western Ambulance Service NHS 4 5 13 The Respiratory past medical history screen enables the clinician to confirm if the patient is asthmatic of suffers from COPD Ts Allergi Priority atic Medi cations Incident i Cardiac Respiratory Diabetes Neurological CA Surgical Gl Palliative _ Familial Other Primary Last Oral J Survey Intake Last Elimi Vital Signs
44. Last Elimi Vital Signs nari Infection Status i Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS f k ae NHS Foundation Trust 4 5 21 The Last Elimination past medical history screen has a data fields relating the patients last urination and bowel movement This allows the clinician to enter information relating to the date and time of the last elimination and additional information such as the presence of blood and or pain This may be relevant if the patient has an acute abdominal pain or is suffering from urinary retention or constipation gt Test Patient i Last Elimination Priority Alerg TEN oo Medi Last Urine Last Bowel Movement cations Last Urine Date amp Time Last Bowel Movement Date amp Time Incident Past Med LEERS Urine Frequency last 24 hours Frequency last 24 hours Primary Last Oral in Survey Intake eaaa Urine Incontinent Incontinent Last Elimi nation Aeau Urine Blood Last Bowel Movement Blood Status Alcohol z A Last Bowel Movement Pain Drugs Ye Secondary Bowel Pain Free Text Survey Vital Signs Drug Inter vention Treatment Discharge response i committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 22 The Infection Status provides a drop down list of common infectious d
45. Nervous System screen has a number of tertiary tabs across the top of the screen that enable the clinician to enter details of the assessment of the patient neurological function These include Stroke TIA Transient Ischeamic Attack Cranial Nerves Visual assessment Sensory assessment TLOC Transient Loss of Consciousness Convulsions Headache and Other to capture any further neurological assessment not captured elsewhere Priority Incident f Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Test Patient erate Nervous System Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication Pathway type Comment Pathway status Convulsions Headache Other Change Enea 0 0 Delete MEND Examination anan Level of consciousness AVPU Speech you can t teach an old dog new tricks Questions age and month Commands close eyes keep them shut then open Facial Droop show teeth or smile Visual Fields 4 quadrants Horizontal gaze side to side Motor arm drift close eyes hold out arms ea Change e 0 0 Delete respons ve 1 COMTUT litte effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 49 The Stroke screen allows the clinician to evaluate whether the patient is suitable for
46. Ok the risk of PE is then provided to support the clinicians ongoing care plans G Priority General Cardi General Croup Assessment Modified Dyspnoea Scale Pulmonary Embolism ovascular f Incident Primary Survey I symptom a Vital Signs Status History Drug Inter vention Treatment Discharge commi aC South Western Ambulance Service NHS NHS Foundation Trust 4 6 30 The Gastro intestinal screen has a number of tertiary tabs that support an depth assessment of the patient 4 6 31 The screen opens on the Diarrhoea screen this enables the capture of data relating to diarrhoea in both tick box format and also with an additional free text field for the capture of information not entered elsewhere Test Patient A eS Gastro intestinal Priority ovascular Incident Ncyelcivel a Does Patient Have Diarrhoea Primary Gastro Number of Bowel Movements in Last 24 hours Survey intestinal GUEC Evidence of Blood in Stool Maternity Neuve Melaena Status System History Vital Signs Muscu loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge responsive committed foe A South Western Ambulance Service NHS NHS Foundation Trust 4 6 32 Constipated screen enables the clinician to capture information relating to any patient who appears to be constipated Data fields are available as either a simple Yes No or
47. Patient Pharmaceuticals Adrenaline 1 100 000 an Route of administratio Adrenaline 1 10 000 Cardiac Arrest PEE nlisted Mggfcation Adrenaline 1 10 000 Post ROSC Adrenaline 1 1 000 fnount Administered Amethocaine 0 5 Dosage Oxygen Mechanism Amiodarone 300mg in 250ml glucose 5 Unit Amiodarone 300mg Aspirin 300mg Additional Comments Atropine 1mg in 5ml 200mjgfograms per ml Atropine 1mg in 59CBRNE _ p ERROR Search Frequency u Time s Guidelines 19 12 2014 12 56 aca Q Cancel 4 7 5 Once the medication is selected other data fields for route of administration dosage and unit etc will pre populate These fields can be overridden and pre populate to support the clinician only Any medication where a dose range can be given will pre populate with the lowest dosage responsive committed g effective South Western Ambulance Service NHS NHS Foundation Trust 4 7 6 The clinician must complete the Administered by section to comply with the legal requirement for all medication administrations to be authorised When not in signal the clinicians 8 digit pin number must be entered in the Given by when out of signal field 4 7 7 Should the clinician accept a Verbal Order for any medication bearing in mind that no verbal order can be accepted for controlled drugs a free text field is provided for details of the prescribing clinician who is providing authorit
48. Patient has diabetes or is taking either oral or injectable medication Yes lt 10 minutes No ns 0 10 59 minutes a Yes 4 em gt 60 minutes ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication ABCD2 Score ABCD2 Score_Type gt test test 123 456 7890 Nervous System TLOC Convulsions Iam LAGH UUV a Has Patient showed signs of acute stroke Has Patient s symptoms 5 Has Patient had previo ABCD2 ABCD2 Score Age BP Speech TIA Duration Diabetes Total 2 2 1 8 05 01 2015 16 07 Qx Cancer Speech TI Duration Diabetes ABCD2 Score ABCD2 Score_Type Convulsions Chang e Normal Headache Other TIA Speech disturbance without weakness Focal weakness or clinical features of TIA i a Headache Other Change am eee 0 0 Delete E o Change 0 0 Delete responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 55 Should the clinician wish to document an assessment of the Cranial Nerves the New assessment button is clicked this then opens up the assessment Priority Incident Primary Survey Vital Signs Status History
49. Resuscitation SCR Date last Seen by GP Care Drug Inter Res vention _ Comment Throm i bolysis Valid DNAR ADRT TEP Cathete Yes Discharge risation 19 12 2014 13 01 Othar Ito pE responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 8 11 The CoD or Confirmation of Death screen enables the clinician to capture details relevant to the verification or Confirmation of Death 4 8 12 Data fields are provide to capture the time of confirmation and the clinician Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge who has verified the death Data fields are also provided to ensure that details of the scene in relation to the patients body and or possessions can be captured either in Yes No format or in the CoD Free Text field provided Test Patient Cardiac Advanced Airway Immobi lisation Muscu LEGGE Confirmation of Death By Burn Inter vention Wound Care Hae Police Notified Time morrhage Patient Left in the Care of Control Police Notified Recognition of Death Respiratory Critical riti Care Pathway type Change Throm Comment pam bolysis Pathway status Va am Cathete 0 0 risation PEE E Delete r responsive i effective fot South Western Ambulance Service hr ee gt a NHS Foundation Trust 4 8 13 In order to confirm death the cl
50. S ti i A p gs Where an Urgent response has been provided following previous Emergency s Safe incident the orginal Incident Number must be entered here R A m S e Vital Signs guarding Patient self conveying a Right Care Status Patient being conveyed by other Ambulance Resource Air Ambul History ae Yes No Provisional Diagnosis _ ________ free Text Secondary Log y Survey matey Attach Drug Inter ne vention Provisional Diagnosis Free Text Treatment Patient Condition on Handover Discharge Referral Spo ntaneous re spirations Spontaneous circulation responsive CEA TIT itec effective South Western Ambulance Service NHS i oh yi NHS Foundation Trust 4 9 6 The See amp Convey screen enables the clinician o document the patients condition on hand over to the receiving clinician This includes status via the large buttons which can be multi selected to include patients for example who have Spontaneous Respirations Spontaneous Circulation and are Alert 4 9 7 Details of the Presenting Condition can be provided using the drop down arrow as below and also with the Provisional Diagnosis Free Text field which will expand as required to capture any information relevant to the Provisional Diagnosis not entered elsewhere within the ePCR 4 9 8 The details of the clinician who is accepting the Clinical Handover can then be entered along with a signature if required
51. Setting and Time Commenced A Free Text field is also available which can be used for the captured of rationale complications etc gt lest Patient Guide lt lt Cardiac CPR ontiation ROSC R i e ithhe Pacing Advanced Airway Immobi lisation Joule Setting Muscu loskeletal aan Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation LON 3 NT responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 8 15 Should the clinician be trained and competent in the use of surgical airway intervention and wish to record this the Surgical Airway screen has a number of data fields many of which are in free text format to capture the intervention Name of Clinician performing this and details of Rationale Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Technique and Complications Test Patient Advanced Intervention Successful Airway lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation fats meee Ww Name of Clinician Time Indication Indication Rationale Technique Used a Complications Surgical Airway Free Text responsive committed South Western
52. Stretcher Incident Aa Vacuum Mattress Vacuum Splint Traction Splint Extrication Other Airway E Primary Survey Muscu ee loskeletal Vital Signs Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Respiratory Drug Inter vention Critical Care Throm bolysis Cathete Discharge risation Oihar Testo v connate South Western Ambulance Service NHS NHS Foundation Trust 4 8 25 The Vacuum Splint screen will appear as below the clinician can then Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge provide details for the limb immobilised by clicking the down arrow The screen also enables the clinician to confirm that post immobilisation whether a Distal Pulse was present gt Test Patient ___ Immobilisation Cardiac Cervical Collar Pelvic Splint Vacuum Mattress Traction Splint Other Advanced acuum Splin Airway Immobi aii lisation Vacuum Splint Applied Extrication Vacuum Splint Muscu Time loskeletal Vacuum Splint Applied Distal Pulse Burn Inter vention Wound Care Time Distal Pulse a Time Hae morrhage Control pa maw No 19 12 2014 13 06 Respiratory ka Critical Care Throm bolysis Cathete risation Oih eT i WwW responsive committed PZA South Western Ambulance Service hz
53. The times from the three actual trials are averaged a Mobility Assessment ree South Western Ambulance Service NHS responsive committed effective fi X South Western Ambulance Service NHS Al ge Sar NHS Foundation Trust 4 6 12 The Cardiovascular screen has a number of tertiary tabs that allow the clinician to document a thorough assessment of the patients cardiovascular system 2G General Priority ECG HeartSounds Oedema JVP DVT Wells Score Incident Respiratory Primary Gastro Survey intestinal Obs amp ee Gynae amp Vital Signs y k Maternity Nervous Status System History Muscu loskeletal Mental Health Exclusion Drug Inter S 2 rug Contrain vention zines dication Treatment Discharge connate P X South Western Ambulance Service NHS am oe wal NHS Foundation Trust 4 6 13 The first tab ECG within Cardiovascular allows the clinician to document the patients ECG the clinician clicks on the New button for a new assessment and then selects the white finger symbol to open a drop down list of heart ee General Priority ECG Heart Sounds Oedema JVP DA Score Incident Respiratory Primary Gastro Survey intestinal Obs amp sees Gynae amp Vital Signs y Maternity Nervous Status System istory History Muscu loskeletal Mental Health Exclusion TL f 2 Drug Inter Contate vention aime dication Treatment Disc
54. Time SS MS Cardiac Rhythm Obs amp Sa aa g Other Saw aaao ynae amp Maternity 0 0 Change Vital Signs Nervous Status System History f Delete Mua Does Patient have implantable cardiac defibrillator in situ loskeletal 5 E Yes Mental Health Exclusion i Contrain vention AAA dication Drug Inter Treatment Discharge 3 11 In the example above once the Guidelines button has been selected the documents as below are provided gt Test Test 123 456 7890 JRCALC Cardiac Rhythm Disturbance Non Traumatic Chest Pain Discomfort Implantable Cardio Defibrillator Adults Heart Failure Adults Clinical Guidelines CG01 Acute Coronary Syndrome amp Stable Angina CGO6 AF amp Hypertension CG32 Vascular Care responsive committed i prone South Western Ambulance Service hZ Sas SS NHS Foundation Trust 3 12 Web Browser provides access to a limited number of external websites This can be used to access the Trust portal and user email accounts and also clinical websites such as Toxbase and Athens way lest Test 123 456 7890 inPrivate fy C Users david partlow O Favorites Default websites 9 n NOt f Athens Registration Or e s British Medical Journal Learning Modules Clin British National Formulary IC U Se CBRNE Training Clinical Knowledge Summaries Cochrane Library College of Paramedics Conflict Resolution Tr
55. a Ko s r w Nah The patient would have benefited from conveyance to a Minor Injury Unit for he purpose of wound closure but they have consistently refused despite advice to the contrary The patient has capacity as per earlier capacity assessment and therefore is able to make an informed decision concerning their on going care The implications of discharge have been fully explained and the options should they wish to self convey to MIU have been provided Drug Inter vention Provisional Diagnosis Free Text Patient Condition on Handover Discharge Referral eee Alert pened Treatment responsive committed effective NHS Foundation Trust z South Western Ambulance Service NHS 3 Main Menu page 3 1 The main menu page is opened automatically as the End User Device EUD is turned on This page provides access to the central functions of the device for both the electronic Patient Clinical Record ePCR and Vital Signs Monitoring VSM 3 2 The Ortivus Logo at the top left of the screen can be used to access information relating to the device by clicking on the Logo you will see details relating to the version of software unit details license number and current configuration software This information may be requested by the Logistics team when reporting a fault 5 Test Test 123 456 7890 emo Vers 2n not for cl Ini MobiMedSmart SO New Patient Logout Open Patient a o Active
56. a nt Contrain y vention SEET _ A dication Date of Last Ectopic Treatment Date Last Menstrual Period Discharge haan Menstrual Period Free Text responsive committed effective r asa South Western Ambulance Service hz NHS Foundation Trust 5 6 44 In order to reduce the visibility of buttons unless they are required the Gestation Period Wks field will only appear if the question Is the Patient Pregnant is answered Yes gt Test Patient AGA Obs amp Gynae and Maternity Guide Cardi Obs amp Gynae Maternity ovascular iiaiai AN 1s the Patient Pregnant espiratory Gestation Period Wks Priority Survey intestinal Obs amp Vital Signs Gynae amp Number Previous Pregnancies Maternity Nervous Status System Number Previous Births History MUR ska Number Previous Miscarriage iterates Health Exclusion Last Miscarriage Date 3 Drug Inter Contras vention dication Previous Ectopic Treatment Discharge responsive committed South Western Ambulance Service NHS if NHS Foundation Trust 4 6 45 The Maternity Screen enables the clinician to enter details of any child birth this will include simple Yes No buttons drop down menus such as Abnormal Delivery to capture details including breech birth dystocia etc and also Free Text fields to capture any information relating to the delivery that are not captured elsewhere This may include the nature
57. aining Datix Dementia e Learning Discovery Library Dynamed Electronic Medicines Compendium Fire Training w Health Protection Agency Health Protection Agency e Learning Highways Agency Information Governance Intergraph Journal of Paramedic Practice Learn with SWASFT Map of Medicine Mental Health Act e Learning Met Office Active Patients 3 13 A number of additional features can be accessed via the Control Panel button on the Main Menu screen ortivus 14 05 3 14 Information relating to network connection can be accessed by clicking on the Network button within the Control Panel This information may be useful if connection to the server is lost and cannot be regained The Logistics Team responsive i committed South Western Ambulance Service NHS NHS Foundation Trust may request this information and prompt the user to ensure that they can access this information ortivus 14 06 Local Contact with local DBI 10 195 137 139 1797 contact with local SQL 10 195 137 139 1797 i Local IP addresses fe80 b8 S492760 f7 db 203411 10 208 82 67 gt lt Mo time synchronization last 24 hours Network iP 10 208 82 67 Primary adapter Ethernet Ethernet Local Area Conmection Ethernet IP 10 208 82 67 MTU 1500 Ping time 155 ms q System SG Server 10 195 137 139 1797 f Gest ada pter to server Broadcom NetXtreme 57xx Gigabit Controller Hostnam
58. al Signs f g Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter Resp ven Critical Care Throm bolysis Cathete Discharge risation f hpi Ww i a cham ESA SVE committed South Western Ambulance Service NHS NHS Foundation Trust 4 8 30 The Musculoskeletal screens provide the clinician with the ability to document the management of Dislocations and Fractures within multiple time fields This allows the clinician to click on the New button to document as many dislocations and or fractures as they have identified Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Cardiac Dislocation Fracture Advanced A Airway Immobi lisation Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Oth ar Latar v cp rin Lil 4 8 31 Once the New button has been clicked within the Dislocation screen the box as below appears This enables the clinician to document in free text format the Location of Dislocation the Management of the that dislocation the Outcome which should include details regarding distal perfusion and distal pulses and any further relevant information such as complications and exclusions within the Comment field ortivus ns Test Patient 13 09 a
59. ance Service hz NHS Foundation Trust 4 6 77 A structured assessment of Lower Leg Injuries for Ankle Foot and Knee Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge are provided by clicking the appropriate New button These assessments help determine whether x ray would be advised General Cardi ovascular Respiratory a Gastro C Spine Assessment Lower leg Assessment Soft Tissue Assessment MFalls intestinal Obs amp Gynae amp Maternity Nervous System Mental Health Exclusion Contrain dication commi A Ee South Western Ambulance Service NHS NHS Foundation Trust 4 6 78 The Ankle Assessment provides the clinician with a series of questions Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Gastro each created to highlight areas of clinical concern A Yes for any of the questions would indicate that an x ray may be required to rule out boney injury An additional free text field is available under Comment to capture any other findings not captured elsewhere Test Patient AAA Musculoskeletal Guide Cardi ovascular Spine Assessment ower Leg Assessmen Soft Tissue Assessment Falls Ankle Assessment __ Respiratory Clinical pathways meen Pathway type Obs amp Gommer Ankle Assessment aS Change
60. arrative or story behind the patients illness or injury within the History of Condition On Arrival History of Presenting Condition HPC field This information is entered within free text format and as with other free text fields this will expand to allow the clinician to enter significant history This free text should however be restricted to the history of the patients illness or injury and should not replace or duplicate data fields contained elsewhere within the configuration Test Patient mil History of Condition sie Condition KESSA ZOU History of On Arrival HPC Condition nation Major Trauma Body Map Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge Other Maps Exclusion Contrain dication responsive committeg effective 4 3 9 South Western Ambulance Service NHS NHS Foundation Trust The assessment of Catastrophic Haemorrhage and evaluation of A Airway B Breathing C Circulation and D Disability are been incorporated into a single screen The functionality of Airway Breathing Circulatory and Disability assessments incorporates a No Assessment is Required functionality For example a patient complaining of a broken finger does not require the clinician to document their airway competency and breathing status This allows the clinician to quickly annotate that this assessment was not required and to move on to
61. ation for Thrombolysis using the down Priority Incident Primary Survey I Muscu Vital Signs f Status History Secondary Survey Drug Inter vention Discharge fats yee Lot a 7 Thrombolysis 7 elect Thrombolysis Indi or lisation l Control Respiratory Critical arrow and then click on New to access the Thrombolysis checklist Once complete the checklist will indicate as below whether the patient is suitable for Thrombolysis gt test test 123 456 7890 Clinical pathways eS Guide SS y mans Advanced within the last six months Airway That the Patient has not had a Stroke of any sort within the last twelve months and no permanent disability from elites No a previous stroke comes Pathway type Immobi Change That the Patient has no diagnosed bleeding tendency has had no recent blood loss except for normal menstruation and is not taking Warfarin Phenindione Nicoumanone Therapy Comment loskeletal ee ee Pathway status Burn Inter vention Wound Care ei sci 0 0 That the Patient has not had any surgical operation significant trauma or head injury within the last four weeks or CPR greater than five minutes Delete ee fp Thrombolysis Free Tex That the Patient has not been treated recently for any morrhage other serious head brain condition or cerebral tumours The Patient is not being treated for liver or
62. ations Past Med EAG E Other Last Oral Intake Is there any Familial history of note Last Elimi nation Infection Status Alcohol Drugs responsive committed P X South Western Ambulance Service NHS LN APN NHS Foundation Trust 4 5 19 The Other past medical history screen has a single free text field which expands as the clinician types This allows the clinician to enter information relating to any other information regarding a past medical complaint or recent illness or injury Ts Allergi Priority IE Medi cations Incident ical Cardiac Respiratory Diabetes Neurological CA Surgical GI Palliative _ Familial Other i Primary SO Survey Intake Vital Signs nates Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge commi aC South Western Ambulance Service NHS NHS Foundation Trust 4 5 20 The Last Oral Intake past medical history screen has a single free text field which expands as the clinician types This allows the clinician to enter information relating to the date and time of the last solid food eaten This may be relevant if the patient may require surgical intervention or is suffering from hypoglycaemia or syncope gt Test Patient NEH Last Oral Intake lt lt Priority a Sever Last Solid Date amp Time cations hasia Past Med ical History Incident Primary Last Oral Survey Intake
63. ave the person sit in the chair with their back to the chair and their arms resting on the arm rests Discharge 2 Ask the person to stand up from a standard chair and walk a distance of 10 ft 3m 3 Have the person turn around walk back to the chair and sit down again Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down responsive committed effective NHS Foundation Trust 4 6 10 The clinician may also wish to record a Mobility Assessment for the patient this would in particular support the determination that a patient is safe to discharge at home and able to mobilise to a sufficient degree to self care and access bathroom facilities and kitchen etc 4 6 11 In order to conduct the assessment the clinician follows the on screen instructions having the patient stand and mobilise for ten feet whilst timing how long this takes ortivus gt Test Patient General General Guide lt lt These people commonly exercise they are among the category one Often they excersise or are very active fittest for their age ocassionally Managing Well People whose medical problems are well controlled but Vulnerable While not dependant on others for daily help often are not regularly active beyond routine walking symptoms limit activitites Mildly Frail These people often have more evident slowing and need Moderately Frail People need help with all outside activ
64. base of the fith Metatarsal Delete Muscu loskeletal Mental Health Boney tenderness in the Navicular Unable to weight bear 4 steps Pathway type Comment Change ei basil 0 0 Exclusion Contrain dication Comment 19 12 2014 12 50 VEAR Pathway status Delete responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 80 The Knee Assessment provides the clinician with a series of questions each Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge created to highlight areas of clinical concern A Yes for any of the questions would indicate that an x ray may be required to rule out boney injury An additional free text field is available under Comment to capture any other findings not captured elsewhere gt lest Patient Spine Assessment General Cardi Soft Tissue Assessment Falls ovascular ower teg Assessmen Respiratory gt S Delete Gastro intestinal Obs amp Gynae amp Maternity Knee Assessment ei Change Age 55 years or older Pathway type Nervous 3 Comment Tenderness at the head of Fibular Pathway status System Isolated tenderness of Patella Muscu loskeletal Mental Health Exclusion Contrain dication Inability to flex to 90 degrees Unable to weight bear both immediately and on assessment Com
65. bulance Service NHS E LANA NHS Foundation Trust 4 9 23 Following the Yes No Don t Know questions additional free test format fields are provided to capture any information relevant to the associated Risk Level and the Victims Priorities 4 9 24 Should the victim be an adult it is also vital that the welfare of any children in the family unit be considered A Free Text field is provided for this purpose Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment but an additional Child Referral may be required Final Disposition Referrals Refusal Safety Net ting Right Care Air Ambul ance Log lest Patient D O OE E an snimak or Tay paT Yes jl No Don t Know Are there any financial issues relating to the abuse Ye s min No Don t Know Has the abuser had issues within the past year with drugs alchohol or mental health Has the abuser ever attempted suicide Has the abuser ever broken bail injunction formal Has the abuser ever been in trouble with the Police or has a criminal history a a aa Is there any other relevant information which may increase risk levels What are the victims priorities to address their safety Do you believe there are risks to children in the family a Yes No If yes ensure you complete Safeguarding referral for children Free Text responsive committed effective South W
66. c Advanced Airway Immobi lisation Lung Palpable and Moving Muscu LEGGE Time of Thoracostomy Burn Inter vention Wound Care Thoracostomy Free Text Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Oihan ee TESKA ISE committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 47 The Critical Care screen has a small number of tertiary tabs each capturing data in relation to interventions carried out by specialist Critical Care staff Only those who have received specific training and authority to carry out these skills should require these data fields 4 8 48 The Thorocotomy screen captures this specialist intervention and requires data input mostly in free text format This enables the identification of all those involved both directly and indirectly in the intervention and details of the procedure itself including Rationale Procedure used Outcome and Complications Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Cardiac Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Othon Loia pera v S Test Patient Clinician Name undertaking procedure Clinician Name supported procedure Consultant Name proc
67. can be Priority Incident Primary Survey Vital Signs f Status History Secondary Survey Drug Inter vention Discharge captured Test Patient Cardiac uee Other Critical Intervention Free Text Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage I Control Respiratory Critical Care Throm bolysis Cathete risation LON NT tc WwW responsive committed g effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 51 Whilst not an intervention used frequently since the use of direct to catheter laboratory pathways have been introduced the Thrombolysis screen captures any use of Thrombolysis in the pre hospital field 4 8 52 The clinician can select the Indication for Thrombolysis using the down Priority Incident Primary Survey Vital Signs f Status History Secondary Survey Drug Inter vention Discharge arrow and then click on New to access the Thrombolysis checklist Test Patient ae Ea Thrombolysis Indication Advanced f Airway Vas Pathway type Immobi lisation A Change Muscu Comment loskeletal Pathway status Burn Inter vention Wound Care Hae la o a a 0 0 Delete Thrombolysis Free Text morrhage Control Respiratory Critical Care Throm bolysis Ben risation Ww 4 8 53 The clinician can select the Indic
68. ce Provided Referrals Incident et tee Has Patient been referred to alternative services Yes ALUGO Safety Net Survey ting Have Family Careers been advised of Ambulance attendance Safe Vital Signs SEGUI Have Care Line been informed of outcome Where appropriate Right Care Yes Ee Health Care Advice Leaflet Provided Air Ambul ance Status History Secondary Log Survey Drug Inter vention Treatment responsive COMTI itec efectwe South Western Ambulance Service NHS NHS Foundation Trust 4 9 17 The ePCR greatly enhances the ability of the clinician to undertake Safeguarding referrals at the patients address As with other screens a large number of data fields have been provided in order to try and capture as much information as possible about the circumstances of the referral and importantly about the soft intelligence that cannot be sourced at a later date This includes the atmosphere at the time of the incident the nature of the environment and any interaction with the Police Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Final Disposition Referrals Refusal Safety Net ting Right Care Air Ambul ance Log Attach ments gt Test Patient Doctor or Urgent Care Service has been informed of Safeguarding Concern Police on scene aware of incident Ce Is Patient in need of Com
69. ce Service NHS NHS Foundation Trust 4 9 22 DASH Domestic Abuse Stalking and Honour Based Violence supports the clinician in capturing information relating to any domestic abuse or situation arising from stalking or honour based violence The tool is designed to assist the clinician in capturing information BUT it should not be read out verbatim but be used as a guide to communication and to assist the clinician in appreciating the information that would be useful lest Patient Final Priority Disposition Referrals Incident Refusal Primary Safety Net PA e T al i e aa STS LCE Is the Patient very frightened Ss es an Is the Patient frightened of further injury or Vika i ee mmm A Vital Signs iaig Ooms the Patient feel isolated from family friends efa YES n n a a el Dean PNE Is the Patient feeling depressed or having suicidal History nce i cuchts eS a cn eA Has the Patient separated or tried to separate from the tK Secondary Log abuser within the past year Survey AC Is there conflict over child contact Drug Inter Se the Patient being constantly called texted i contacted followed stalked or harrassed Is the Patient pregnant or had a child within the last Treatment eighteen months Is the abuse happening more often Is the abuse getting worse Is the Patient excessively controlled or subject to y N Don t Know responsive committed effective South Western Am
70. clicking Best Interest the clinicians rationale must be entered here ortivus Test Patient Priority Dacia Patient Patient else Is Patient Over 16 Cention m S ce x _N ew Primary a S ivey Consent for Assessment amp Treatment Pathway type Change Y No Best Interest one s Consent to Share Information lt gt Vital Signs Pathway status Mets kans Yes No Best Interest 0 0 Status Consent Signature Delete History Secondary Survey Drug Inter vention Patient Not Able to Sign Treatment Discharge ONSE COP iT wbx efecte South Western Ambulance Service NHS NHS Foundation Trust 4 2 17 The Mental Capacity Act requires all clinicians to consider that all patients have the capacity to make decisions about their care until such time as the assessment of capacity determines otherwise Itis not sufficient to undertake an assessment and determine capacity without appropriately documenting the decision making process and rationale for any determination which subsequently impacts on the patients care 4 2 18 By clicking the New button within the Capacity Assessment box a checklist Priority Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge ortivus will appear to assist in the assessment of capacity This assessment will be based on an adult capacity assessment if the Is the Patient Over
71. conveyance to a hyper acute stroke centre in line with Clinical Guidelines On clicking the New button the screen as below is displayed The three qualifying questions are asked and if all Yes the patient is deemed suitable for conveyance to the hyper acute stroke centre Timeframes for conveyance are contained within the relevant Clinical Guideline this can be accessed via the Guidelines button on the screen or via the Guidelines function on the Main Menu screen gt Test Patient ortivus err Nervous System Priority Convulsions Headache Other ovascular Incident Stroke Suspected Respiratory um Clinical pathways Pathway type ia pE yaa Primary Gastro Survey intestinal Obs amp Comment Gynae amp Maternity Stroke Suspected Vital Signs Pathway status Nervous Is Blood Sugar Greater than 3 5 mmol History FPE Lo Can Patient Arrive at Hyper Acute Stroke Unit within Pee MEND Examination Timeframe for Stroke Thrombolysis Vak Sa Vaaa a Is Patient Over 18 Mental GS asl sa Health Comment Level of consciousn Ch Exclusion Ti ange Bem ail ee Speech you can t te me venton s dicat A i 19 12 2014 12 38 al ages piee Questions age and ia kaiia re canines aa Ox O cone Facial Droop show t Delete Visual Fields 4 quadrants Discharge Horizontal gaze side to side Motor arm drift close eves hold out arms
72. data for multiple injuries by clicking the New button for each wound managed gt Test Patient Meo Wound Care 6 Guide Priority Cardiac New _ Incident Advanced i Irrigated Change Airway l ai immabe Local Anaesthetic Applie Primary eS lt gt Survey ie lisation Nerve Block i 0 0 eco Nerve Block Free Text loskeletal Delete a b SIet Ga R Dressing Applied Wie Dressing Applied Free Text Status i History Dressing Applied Time Dressing Applied Location Hae SSCA Wound Closure Survey Control Number Applied Drug Inter Respiratory vention Time Applied Critical Care Suture Size eee Suture Free Text bolysis Cathete Discharge risation Fats Oo ae Ww responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 36 Once the New button has been clicked the Wound Care screen appears as below The clinician can select whether the wound has been Irrigated and cleaned whether Local Anaesthetic has been applied the use of Nerve Blocks for those trained and deemed competent in this skill can also be documented 4 8 37 The clinician can select any Dressing Applied from a drop down list by clicking on the white finger symbol or use the Dressing Applied Free Text field to capture information related to any dressing used that is not listed 4 8 38 In order to select the Wound Closure method used the clinician clicks on the drop do
73. e 17011111 Nc Ping DBI server TCP 2 10000 bytes 155 ms 10 195 137 139 1797 Result Ok 3 15 Updates will periodically be available for the EUD this may take the form of new guidelines for example or changes to update the configuration The Remote Update function allows the software to be updated remotely without a physical connection to the server 3 16 When updates are available the green Update icon u will appear in the bottom right of the screen and the update can be accessed via the Control Panel ortivus 14 06 20 08 2014 14 01 00 Check updates on serwer 10 195 137 139 1797 20 08 2014 14 01 00 GetUploadPath D Ortivus Uploads 10B1 9525 8D0D 44E9 20 08 2014 14 01 00 RemoteUpdatePath DAOrtivus RemoteUpdate 14 08 18 32 20 08 2014 1401 00 All files in Updates xml are up to date 20 08 2014 14 01 00 GetGuidelinePath D Ortivus Guidelines localGuidelineFolder quidelines 20 08 2014 14 01 01 Download DA Ortivus Guidelines Guidelines xml zip from 10 195 137 139 1797 to quidelines Guidelines xml zip 20 08 2014 14 01 01 GetFile File exists Will resume quidelines Guidelines xml zip 20 08 2014 14 01 01 Sucessfully downloaded file quidelines Guidelines xml_zip 20 08 2014 14 01 02 All files in Guidelines xml are up to date 20 08 2014 14 01 02 Next check for update at 20 08 2014 15 01 02 responsive committed South Western Ambulance Service NHS NHS Foundation T
74. e Text and Exclusion responsive cammed effective yeaa South Western Ambulance Service hz 54 NHS Foundation Trust 4 4 4 Once a New set of observations is selected the screen below will appear many of the observations will have pre set values such as Pulse for example If the clinician clicks on the pulse box a value of 70 will appear this can then be adjusted upwards or downwards as appropriate by using the or buttons 4 4 5 Ifa set of observations that would normally be required to support a clinical intervention or assessment have not been taken a Vital Signs Free Text and Exclusion field is available within the Vital Signs screen to capture the clinicians rationale gt lest Patient Heal Ci Vital Signs Priori Vital Signs g Ne Incident tine Change Primary Method of Capture Resp Survey z m sil PEFR 60 800I pm PEFR Patient s Norm 60 800I pm PEFR Unable Refused Status History _ E Vital Signs Free Text and Exclusion Secondary Survey Drug Inter vention Treatment Discharge responsive committed efective South Western Ambulance Service NHS j fe oe NHS Foundation Trust 4 5 Primary Tab Status History 4 5 1 The Status History of the patient tab enables the clinician to capture data that is relevant to the patients past medical history This may
75. eal opportunities in terms of research in to pre hospital care research that up to this point has been incredibly onerous and reliant on review of paper based systems Data Entry The system is designed with a large number of data entry fields these take the form of simple boxes to click which indicate a positive or negative Yes and No boxes drop down checklists decision support tools and free text fields Free text boxes expand as data is entered they should be used to provide supporting information for the other forms of data entry and to provide a narrative or to provide information which does cannot easily be entered as a single button Boxes and drop down selections assist the clinician guide decision making where appropriate and also ensure that the information that may be required by the Trust for clinical audit research and for external agencies such as the Police and Coroner is available Only data relevant to the patient s assessment or examination need be completed whilst multiple data fields exist not everyone is relevant to each and every patient interaction The system is designed to cover all patient groups if it is not relevant to the patient in front of you don t fill it in All data you may wish to enter has a corresponding field get used to the system and learn where the data entry points are As experience grows the use of the system will support greater clinical record keeping and enable you to make use of the
76. ection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 15 The CA Surgical G past medical history screen enables the clinician to confirm whether the patient has a cancer diagnosis and if so to identify the approximate date of that diagnosis It also allows the clinician to enter additional information relevant to the patients relevant Surgical history or an GI Gastro intestinal history of relevance gt Test Patient Priority Allergies Past Medical History YEE Past Medical History of Note cations Past Med ical History Incident Palliative Familial Other Primary Last Oral Survey Intake Last Elimi Vital Signs nanei Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 16 The Palliative past medical history screen enables the clinician to confirm whether the patient is being actively managed as end of life It also allows the clinician to enter additional information in free text format relevant to any DNAR Do Not Attempt Resuscitate Order TEP Treatment Escalation Plan or Advanced Directive 4 5 17 The Palliative past medical history screen also enables the clinician to con
77. ed the Falls Referral if selected would be missing a large proportion of its data and not be fit for purpose The main record can also be used by the clinician to review all data entered thus far so as to ensure that the patients assessment and management Is appropriately documented prior to closing and signing the record 4 9 11 Once the record is finalised and ready for appropriate referral the clinician can select Send Report to access a closed list of appropriate email addresses Test Patient Final Referrals Priority Disposition S Referrals Acute Care Referral Form Referrals Incident Refusal 4 a aop af Send report Main Record Primary Safety Net Survey ting i in Safe guarding uns Vital Signs South Western Ambulance Service NHS Right Care Sei oundsetion Trust Status i Air Ambul History ance Secondary Log Main Record Survey eee Attach Drug Inter 4 __ Ments Details vention Vehicle Call Sign DavePTestCWS Treatment Patient Patient f Patient Forename Test Type text to find responsive committed effective NHS Foundation Trust pont South Western Ambulance Service hZ 4 9 12 Once Send has been selected the appropriate email address can be sourced using the white drop down arrows as below This will enable the onward referral of patients to services who have provided a secure NHS email account Any additional in
78. edure discussed with Time Decision to Proceed Time Pericardium Opened Indication Was tamponade present Yes Was cardiac injury identified es Was cardiac injury closed S Last Signs of Life Time Rationale Free Text Procedure Free Text Outcome Free Text Complications Free Text Other Intervention TESKA ISE committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 49 The RSI Rapid Sequence Induction screen as shown below captures this specialist intervention and requires data input both as binary Yes No and free text format This enables the identification of all those involved both directly and indirectly in the intervention and details of the procedure itself including Rationale Procedure used Outcome and Complications ortivus n Test Patient 13 14 A Critical Care Priority Cardiac Thoracotomy Wee Ga One Clinician Name undertaking procedure Airway Immobi Primary lisation Survey Clinician Name supported procedure Muscu me LEGGI Consultant Name procedure discussed with Viel sae Burn Inter vention Time of Decision to RSI Status Wound Aspiration During Procedure History Care i j Hae Time of a e Secondary morrhage SpO2 Under 92 at any one time Survey Control Indication RSI Free Text Drug Inter Respiratory Dental Trauma ed Critical RSI Free Text CO Care Systolic BP Be
79. en for three days or more Localised tenderness along the distribution of palliative immobilisation of the lower extremeties or major surgery within twelve weeks the deep venius system No No requiring general or regional anaethesia No has o Mo nm Yes n Yes Gon n Yes Entire leg swollen Calf swelling Pitting odema Collateral Calf swelling at least 3cm larger than Pitting odema confined to the symptomatic Collateral superficial veins non varicous No asymptomatic side leg No 0 No 0 No mi Yes lammene ma Yes 1 Yes m Yes ama DVT Alternative diagnosis Previously documented DVT An alternative diagnosis is at least likely as a z 5 No DVT Vnan y No Pm a Yes m ESI TE committed effective 2 9 ortivus Priority Incident f Primary intestinal Survey Vital Signs Status Drug Inter vention Treatment Discharge Cardi ovascular Obs amp Gynae amp Maternity Nervous System History f Muscu loskeletal Mental Health Exclusion Contrain dication South Western Ambulance Service NHS 5 Test Test 123 456 7890 eem Cardiovascular Change NHS Foundation Trust An outcome is then provided either in terms of the relevant risk or with specific guidance as below 2 10 Within some screens as in the ECG screen within Cardiovascular which allows the clinician to document the patients ECG a white finger symbol is used t
80. ervous System Muscu loskeletal Mental Health Exclusion Contrain dication S gt Test Patient Gastro intestinal Diarrhoea Is abdomen soft Is abdomen rigid Is there evidence of guari Is there evidence of rebo Is there evidence of a pul Is abdomen distended PR Bleed Ascities Hernea inguinal umbilic femoral Masses Free Text Pain Location et Abdominal Assessment r 0 7 tipa jo Time 19 12 2014 12 32 Is abdomen soft Is abdomen rigid Is there evidence of guarding Is there evidence of rebound tenderness Delete Is there evidence of a pulsatile mass Is abdomen distended Ascities Hernea inguinal umbilical epigastric inscisional femoral Masses Free Text eae Change responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 37 In order to identify the location of any abdominal pain the clinician first clicks on the white finger symbol this then opens up a checklist of abdominal Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular Respiratory Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication 19 12 2014 12 32 ai commi South Western Ambulance Service NHS NHS Foundation Trust 4 6 38 A generalised Urinary As
81. estern Ambulance Service NHS NHS Foundation Trust 4 9 25 As the Trust concentrates on providing the Right Care in the Right Place and at the Right Time is important that we capture details of any incident where we have been prevented from delivering that care This may be because the appropriate alternative service does not exist or will not take direct referrals from the ambulance service This information is collated on a monthly basis and fed back to Clinical Commissioning Groups so it is vital that this screen is completed every time the Right Care is not delivered 4 9 26 As part of the financial commitment provided by central government to the delivery of the ePCR the Trust is committed to deliver a wider benefit to the NHS The question Did the ePCR assist you in providing the patient with the Right Care has therefore been included as a mandatory question within the ePCR configuration This will assist in evidencing the benefit and providing assurance against the financial outlay Test Patient ULE Right Care Priority Disposition What has stopped you providing the right care to your Patient today Referrals Incident ATAR Would your Patient have benefited from better access from any of the following Primary Safety Net ff Survey ting Free Text Safe guarding Vital Signs Does this alternative service exist locally Right Care Yes No e OCS Ml E Did this alternative service decline to assist History
82. ew button ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Stroke TIA Cranial Nerves Visual Sensory TLOC Convulsions Headache Other YEGUA Uni Muscu loskeletal Mental Health Exclusion Contrain dication cp rin Lil South Western Ambulance Service NHS if NHS Foundation Trust 4 6 61 The Sensory assessment enables the clinician to review loss of sensation Tone and Sensory Power This may be supportive of an assessment of spinal injury or spinal compression and assist in determining the location of any injury 4 6 62 Any bi lateral loss could be indicative of spinal insult the Level of Impairment field below allows the clinician to approximate the level of impairment by relating the loss to the relevant dermatome gt Test Patient Priority Genea Systa Sny ______________ Cardi eepe N Dna Patient have bi lateral sensory impairment ovascular J Incident R Respiratory Deval of n Primary Gasires Does Patient Survey SS Level of Impai anu Free Text Obs amp Gyna i Impairment Fr yaeu Unilateral Loss Unilateral Loss Nervous Status Systems Unilateral Loss Yes History PE Tone Unilateral Loss Free Text loskeletal Right Arm Mental Tone Health Left Arm Exclusion Righ
83. fa Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge comm aC Ya South Western Ambulance Service hz YE a ae NHS Foundation Trust 4 5 14 The Diabetic past medical history screen enables the clinician to confirm if the patient is either Type One or Type Two diabetic it also provides a free text option should the clinician wish to enter additional information relevant to the patients diabetes Priority Allergies VE Past Medical Histo cations LLL Incident aya ical History Cardiac Respiratory Diabetes Neurological CA Surgical GI Palliative Familial Other Primary Last Oral Survey Intake Last Elimi Vital Signs a Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 14 The Neurological past medical history screen enables the clinician to confirm whether the patient has suffered a previous TIA or Stroke and if so to identify the approximate date It also allows the clinician to enter additional information relevant to the patients hypertensive or epileptic history gt Test Patient Priority MELE Past Medical History Guide lt Medi Past Medical History of Note cations Incident Palliative Familial Other Primary Last Oral Survey Intake Last Elimi Vital Signs naton Inf
84. figured so as to take the clinician through a structured process capturing any and all clinical interventions and where possible and appropriate incorporating validated assessment tools to enhance the clinical decision making process This in turn allows the clinician to use the device to support their clinical assessment and ensure that patients are conveyed or signposted to the most appropriate service The product offers full N3 connectivity at a Clinical Workstation connecting the individual end user device via the 3G network This allows the acute trust and other clinical partners to view the appropriate record and provide early indication of potential patients with regards levels of acuity and likely interventions The device also provides for full NHS Spine connectivity and will therefore support both the Summary Care Record and Enhanced Summary Care Record The solution communicates to a Vital Signs monitoring equipment also provided by Ortivius This Mobimed system communicates via Bluetooth to the ePCR auto populating biometric data making the transition of such data quickly available to the acute trust via the N3 network and Clinical Workstation This workstation is alertable and incorporates an instant messaging functionality to allow for rapid review of ECG and supportive communication between hospital and pre hospital clinician The capture and controlled transmission of patient data is available in the form of highly configurable
85. firm whether the patient has a Lasting Power of Attorney consideration should be given to whether the patients Lasting Power of attorney has power over financial matters or in addition has power to make decisions for those relating to health matters Test Patient Priority MECE Past Medical History VCE Past Medical History of Note cations Past Med ical History Incident Palliative Familial Other Primary EROE x F i E Survey ee Is Patient being managed as being Palliative Last Elimi YRS Lee Ginna ONAR TEP Advanced Directive MART Does Patient have valid DNAR TEP Advanced Directive Status Yes No Alcohol Free Text Drugs Secondary Survey Power of Attorney Does Patient have Lasting Power of Attorney bug SS e Sa vention Free Text Treatment Discharge responsive Comm itteg effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 18 The Familial past medical history screen has a single free text field which Priority Incident Primary Survey Vital Signs Secondary Survey Drug Inter vention Treatment Discharge ical History esis expands as the clinician types This allows the clinician to enter information relating to the patients familial history This could include details of parents cardiac history or siblings cancer diagnosis etc Test Patient Allergies Past Medical History WEEE Past Medical History of Note c
86. format field for the recording of specific details gt Test Patient a sri Cardiovascular Guida Cardi ovascular J Additional Sounds Present Respiratory j Additional Sounds Free Text intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 17 Should the clinician wish to record an assessment of Peripheral Oedema this assessment can be recorded within the fields below A simple Yes No can be used to identify if any Oedema is present and a free text format field for the recording of specific details gt Test Patient Re eri Cardiovascular Guidas Priority Cardi Ea i ovascular Incident Respiratory Is Peripheral Oedema Present Si A G PO Present Free Text Survey intestinal Obs amp Gynae amp Vital Si i aa Maternity Nervous Status System History Muscu loskeletal Mental Health D Exclusion rug nter Contrain vention ee dication Treatment Discharge responsive committed effective South Western Ambulance Service NHS if NHS Foundation Trust 4 6 18 Should the clinician wish to record an assessment of Jugular Venous Pressure this assessment can be recorded within the fields below A drop down list can be accessed to identify if the JVP is
87. formation which is required in order to provide the recipient with guidance as to why the email referral is being sent can be entered into the message text box as below 5 test test 123 456 7890 a Referrals Priority Disposition eters Referrals Ae Send mail Refusal D a BEF report Main Record Destination East Incident Primary Safety Net Survey ting Safe Somerset Vital Signs guardi Musgrove Park TIA Clinic Right Care Status E mail receiver tst tiareferrals nhs net History Air Ambul ance Subject TIA referral Secondary Log Survey Message text Attach ments Please find attached TIA referral for patient attended by ambulance today all details have been provided within the on appropriate referral Drug Inter vention Treatment Type text to find responsive committed yeaa South Western Ambulance Service h z KJ NHS Foundation Trust 4 9 13 The Refusal screen enables the clinician to capture details of any patient who declines treatment and or transfer against the clinicians advice The Patients Signature along with Attendant Signature and any appropriate Witness Signature can all be captured by clicking Sign and then by using the stylus to sign directly onto the screen Itis important that the patient is given the opportunity to read the Patient Declaration or that this is communicated to them by other means a
88. ften they excersise or are very active fittest for their age ocassionally Managing Well People whose medical problems are well controlled but Vulnerable While not dependant on others for daily help often Obs amp are not regularly active beyond routine walking symptoms limit activitites OUR Mildly Frail These people often have more evident slowing and need Moderately Frail People need help with all outside activities and with Maternity help in high order activities of daily living Typically mild keeping house Inside they often have problems with Nervous frailty progressively impairs shopping and walking outside stairs and need help with bathing and dressing Status System alone meal preparation and housework History T Severely Frail People who are completely dependant on personal care Very Severely Frail People who are completely dependant approaching end from whatever cause physical or cognitive Even so they of life seem stable and not at high risk of dying Mental Terminally Ill People approaching end of life this category applies to Health people with a life expectancy of under six months nic sasad 1 Very Fit 2Well 3 Managing Well 4 Vulnerable S Mildly Frail 6 Moderately Frail _ vention dication z i Treatment Mobility Assessment The person may wear their usual footwear and can use any assistive device they normally use Primary Gastro Survey intestinal Vital Signs Muscu loskeletal 1 H
89. ge Test Patient General ovascular enera TOUD ssessment zdi P Modified Tausig Score Respiratory stridor Recession Total Gastro Change lamas J intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication responsive committed E A South Western Ambulance Service hz TEN NHS Foundation Trust 4 6 26 The Modified Tausig Score captures the degree of Stridor a harsh vibrating sound caused by obstruction of the larynx and the degree of Recession The degree of stridor and or recession will be recorded as None On Crying or Exertion At Rest and Severe Biphasic both inspiratory and expiratory ae General Priority Cardi General Croup Assessment Modified Dyspnoea Scale Pulmonary Embolism ovascular f Incident Survey intestinal Obs amp ee Gynae amp Vital Signs y Maternity Nervous Status System Heston Muscu loskeletal Mental Health Exclusion Drug Inter z g Contrain vention ae dication Treatment Discharge commi aC South Western Ambulance Service NHS NHS Foundation Trust 4 6 27 The Modified Dyspnoea Scale is used to evaluate and record the degree of Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge breathlessness and whether this occurs at rest or at exertion The clinician sim
90. harge commi aC A Ee South Western Ambulance Service NHS NHS Foundation Trust 4 6 14 The drop down list of rhythms enables the clinician to select multiple fields for example a patient with pacemaker who has a sinus rhythm 4 6 15 The drop down list also incorporates an Other field when selected the date time rhythm field shown in 5 6 13 will also incorporate a free text field to capture details of the clinician assessment ortivus lest Patient ane earl Cardiovascular Priority Cardi ovascular Incident Respiratory up Cardiac Rhythm sous ibys sania lames Primary Survey Vital Signs Status History Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu ECG Date amp Time Cardiac Rhythm Other aiiai AV Block Type 1 AV Block Type 3 tial Fibra Change a bai 0 0 Delete loskeletal Mental Health D ini Exclusion rug inier Contrain vention Bre dication Treatment Discharge i response committed A Ee South Western Ambulance Service NHS NHS Foundation Trust 4 6 16 Should the clinician be competent in the assessment of Heart Sounds this Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Gastro assessment can be recorded within the fields below A simple Yes No can be used to identify if any additional sounds are present and a free text
91. he white finger symbol This then opens the drop down menu below from which the clinician can select multiple sites ea lest Patient Cardi ovascular Incident REECE Primary Gastro Survey intestinal Obs amp Vital Si pecs Maternity Nervous i r Wong Baker Pain Vocalisatior New lt AIGNT Flank Scale System x ange History Niece eft A ac Anterio p Mental Health SPE ne raci Ca dia z Poste io A Righ der Exclusion E Contrain 0 0 n p a r RIC pper Arm dication z a Drug Inter vention Treatment Discharge responsive committed 4 6 6 4 6 Priority Incident f Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge South Western Ambulance Service NHS NHS Foundation Trust An evaluation of pain is an essential component of the patient assessment In order to better capture the assessment across a range of patients the clinician is provided with a detailed assessment screen that is accessed by clicking the New button within Pain Score A simple O to 10 pain score can be entered using the drop down button in Pain Score Alternatively for paediatrics the Wong Baker Pain Scale can be used to determine a child s pain score Additionally the Abbey Pain Scale a tool for assessing the pain of a patient who is unable to express this can be accessed by clicking the Change button within the Abbey Pain
92. ided to support the clinician in finding the appropriate medication 4 5 5 Once the medication is found the clinician highlights the appropriate medication and clicks Add this enters the medication as an allergy Multiple selections can be made at this point Once all medications to which the patient is allergic have been selected the clinician clicks on Ok gt lest Patient Medications Allergies Aciclovir Acrivastine Alendronic acid Alfacalcidol Alfuzosin Allopurinol Almotriptan Amantidine Amiloride Aminophylline Amiodarone _ Remove responsive Comm ittheg effective South Western Ambulance Service NHS NHS Foundation Trust 4 5 6 The Medications tab enables the clinician to enter information relevant to medication that the patient is currently prescribed An additional Free Text Field is available which can be used to identify any medications which may have recently been added or are short term such as recent antibiotics etc 4 5 7 The Medications screen also allows the clinician to identify if the patient is currently non compliant with their medications and a Medications Comments free text field is available to expand on any current issues in relation to the patient medications this may include details concerning any review or any gap in medication history 4 5 8 In order to enter a current medication the clinician first needs to click on the white finger symbol gt
93. include information that relates to any long term conditions and also any recent illness or injury that may be relevant to any care being considered by the clinician or those who may deliver any subsequent definitive care 4 5 2 The Allergies tab enables the clinician to enter information relevant to medication allergies and also those relating to Latex An additional drop down menu is available for allergies relating to plasters and foodstuffs An additional free text field is available as Other which can be used to capture information relevant to any sensitivities that fall short of true allergy or other pertinent information of use for those who may be providing ongoing care 4 5 3 In order to enter a medication allergy the clinician first needs to click on the white finger symbol ortivus Test Patient 12 04 ies Allergies ES Priority Allergies Vent Medications Allergies cations Past Med ical History Primary ENLOF Allergies Survey Intake Last Elimi ansan nation Vital Signs Latex Infection Status Alcohol Drugs Incident Secondary Survey Drug Inter vention Treatment Discharge South Western Ambulance Service hYZ A if NHS Foundation Trust 4 5 4 Once the white finger symbol is clicked the screen below is displayed This enables the clinician to select medications that the patient is allergic to from an alphabetical list An additional Search functionality is prov
94. inician must click on the New button within the Recognition of Death box and work through the checklist provided The clinician will be taken through the required questions and exclusions for confirmation prior to being given confirmation or otherwise ortivus Test Patient 13 02 Priority Clinical pathways Cardiac RecognitionOfDe th Incident Advanced Airway Immobi Asystole over 30 sq tonds Absent heart soundf Primary Survey lisation Muscu LA GGE Confirmation of Death Vital Si 4 5 tal agi Burn Inter Exclusion vention Status Wound Police Noti E Pregnancy History Care Drowning suWmersion adult under 60 mins child under Hae Police Notified Time o0 mins Secondary morrhage Survey Control _ Hypothermia Recognition of Deat Overdose om Confirm recognition of death Pathway type Drug Inter hi vention Critical Care Throm Comment Comment boias Pathway status Time Cathete Discharge risation 19 12 2014 13 01 2 ce N38 Nn eT i Fae en v responsive committed Appr South Western Ambulance Service NHS NHS Foundation Trust 4 8 14 Should the clinician be able to carry out Pacing this screen allows for the Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge capture of information relating to the Rate Joule
95. ischa rge risation responsive committed pE South Western Ambulance Service h z KJ NHS Foundation Trust 4 8 33 The Burn Intervention screen enables the clinician to document the application of cooling for any burn whether this has been removed potentially to reduce complications of hypothermia and within the Cooling Applied Free Text any relevant information such as the rationale for removing the cooling 4 8 34 The screen also captures data regarding Water Gel and Cling Film application along with a final free text field for any Other Intervention not captured elsewhere S gt Test Patient R Burn Intervention Priority Cardiac Cling Film Applied Incident Advanced UA Cooling Applied Time Cling Film Time Primary Immobi Survey i Cooling Removed Time Muscu loskeletal BurnmInter Cooling Applied Free Text vention Status Utu E Water Gel Dressing Applied History Care j E n S Hae Secondary morrhage Dressing Applied Time Survey Control Other Intervention Vital Signs Drug Inter Resp ven Critical Care Throm bolysis Cathete Discharge risation Oihan lat ar v TESKA ISE committed effective i South Western Ambulance Service h z KJ NHS Foundation Trust 4 8 35 The Wound Care screen will predominantly be used by ECPs Emergency Care Practitioners and those deemed to be competent in the management of minor injuries This screen allows for the capture of
96. iseases which can be used if the patient has a confirmed infection This includes C Difficile and Norovirus This would be essential information for any receiving hospital 4 5 23 The clinician is also provided with a free text field which expands as the clinician types to capture any further information which may be relevant This could include issues such as scabies etc S Test Patient MEH Infection Status l lt Priority aa 88 Medi Infection Status cations Past Med ical History Free Text Incident Primary Last Oral Survey Intake Last Elimi Vital Signs nane Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive Comm ittheg effective A Ee South Western Ambulance Service NHS NHS Foundation Trust 4 5 22 The Alcohol Drugs screen provides a free text field which expands as the clinician types to capture any further information which may be relevant in relation to alcohol and or recreational drug use lest Patient ZE Alcohol Dru ce Priority Allergies Alcohol Drugs OOO n Medi cations Incident Past Med ical History Primary Last Oral Survey Intake Last Elimi Vital Signs ton Infection Status Alcohol Drugs Secondary Survey Drug Inter vention Treatment Discharge responsive committed 4 6 4 6 1 4 6 2 4 6 3 Priority Incident Primary Survey Vital Sig
97. ities and with Primary Gastro help in high order activities of daily living Typically mild keeping house Inside they often have problems with frailty progressively impairs shopping and walking outside stairs and need help with bathing and dressing alone meal preparation and housework Severely Frail People who are completely dependant on personal care Very Severely Frail People who are completely dependant approaching end from whatever cause physical or cognitive Even so they of life seem stable and not at high risk of dying WT Terminally Ill People approaching end of life this category applies to Status System people with a life expectancy of under six months History Priority Cardi ovascular Incident Respiratory Survey intestinal Obs amp Gynae amp Vital Si ieee Maternity Muscu loskeletal Mental Health Exclusion Contrain ver AIA 1 Have the person sit in the chair with their back to the chair and their arms resting on the arm rests 2 Ask the person to stand up from a standard chair and walk a distance of 10 ft 3m 3 Have the person turn around walk back to the chair and sit down again Drug Inter The person may wear their usual footwear and can use any assistive device they normally use Treatment Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down The person should be given 1 practice trial and then 3 actual trials
98. low 90 at any time Throm e AA Number of Intubation Attempts Cardiac A 3 Cathete lia Decis Ee Grade of View e C iais sai nial oo Leda wee ortivus Test Patient 13 14 A Critical Care Priority Cardiac Thoracotomy RSI Other Critical Incident Advanced j Indication RSI Free Text Airway Dental Trauma Primary Immobi Y Sive IE RSI Free Text y Systolic BP Below 90 at any time Muscu loskeletal ARE E IA ital Si um Intuba ttempts Vital Signs Burn ee Pasar aivast vention n Lau Status Vetta Grade of View a History Care n n Was Plural Drainage Required e ding Size Tracheal Tube aii Secondary morrhage minnn ua aas a Survey Control laca laa Tube Length at Lips cm Drug Inter Respiratory j B f ws ft vention Critical ia Was an Introducer used Care Thron a NO SS ele a Was a Bougie used Cathete Yes No Discharge risation Was a Supra Glottic Airway used ee LON 8 No Ten Fs mme v responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 8 50 Given the nature of Critical Care and the need to provide specialist interventions outside the acute setting the Other Critical screen enables the clinician to capture any other intervention that has been attempted or provided in free text format This data field will expand as required to ensure all interventions rational procedures complications and exclusions
99. me Password Domain A STATIONS 3 7 Open Patient this function enables the user to look at closed but not signed records This will for example allow a crew to pick up a record started by an RRV that relates to a patient they are subsequently being asked to convey ortivus 4 MobiMed Smart ae i SD Men patient aa cine i Web browser 3 8 Onclicking Open Patient a list of incidents will appear which can then be selected responsive committed E ME 2 South Western Ambulance Service hZ AJ NHS Foundation Trust ortivus 14 01 Filter From eee Freetext 18 08 2014 14 59 Teo paene l Jpdate To Region Intended Destination Hospital Skip signed 20 08 2014 14 59 Showing 45 entries 20 08 2014 11 43 04 Fy Somerset 7820161 4504 M 20 08 2014 10 47 26 Fy Somerset 7819991 4507 M 20 08 2014 10 03 17 PA Somerset 7820008 4504 M 20 08 2014 09 32 21 PJ Somerset 7819958 4510 M 20 08 2014 08 54 54 Fy Somerset 4511 M 20 08 2014 08 38 32 PJ Somerset 7819863 4504 M 20 08 2014 07 04 38 Fy Somerset 7819841 4507 M 20 08 2014 06 51 42 PJ Somerset 7819832 4511 M 20 08 2014 03 35 38 Fy Somerset 7819741 4507 M 20 08 2014 03 31 27 PA Somerset 7819739 4510 M 20 08 2014 01 23 03 P3 Somerset 7819657 4511 M 19 08 2014 22 58 38 Fy Somerset 7819521 4511 M 19 08 2014 22 24 57 L Somerset 7819492 4511 M 19 08 2014 21 26 2
100. me Survey y Drug Inter Vehicle Call Sign vention DavePTestCWS First At Scene Treatment Discharge South Western Ambulance Service NHS NHS Foundation Trust 4 2 5 The Patient Screen enables the clinician to enter information relating to the Patient It includes the option to add a preferred name or a name by which the patient is known other than their primary christen name 4 2 6 Additionally a Patient Address same as Incident Address button is available by clicking this the Patient Address fields will auto populate with information captured in CAD relating to the Incident Address 4 2 Priority Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge Drop down boxes are provided to support the capture of standard demographics including Ethnicity Social History Religion and Sexual Orientation Additional free text fields are provided for Social History and Occupational History Information relating to the nature of the patient s occupation may be important for hand fractures or injury relating to the ability to care for a dependant or to drive for work etc acne Patient ei To CoD O G ae A a Patient Contact Number Date of Birth Gender Patient Surname X Patient Personal Demographic Service X a_a Cancel Ethnicity Social History Social History Free Text Occupational History Free Text Religio
101. ment Pathway type 19 12 2014 12 51 DK Qon Change Eses 0 0 Lista Comment Pathway status a Delete responsive i committed fi X South Western Ambulance Service NHS NHS Foundation Trust 4 6 81 The Soft Tissue Assessment provides the clinician with an opportunity to document the assessment of any soft tissue injuries The clinician accesses the data fields by clicking the New button Multiple assessments can be entered simply by creating a new assessment by clicking the New button to open up the data fields as required a General Priority Cardi ovascular f Respiratory in Primary Gastro C Spine Assessment lowerleg Assessment Soft Tissue Assessment Falls Incident Survey intestinal Obs amp EE Gynae amp Vital Signs y k Maternity Nervous Status System History Mental Health Exclusion Drug Inter Contrai vention SAONA dication Treatment Discharge connate fi South Western Ambulance Service NHS NHS Foundation Trust 4 6 82 The Soft Tissue Assessment captures data relating to Swelling and Contusion It also has free text fields to capture details of any Wounds and Foreign Bodies wae General Priority Cardi C Spine Assessment ovascular f Respiratory l Primary Gastro Incident Survey intestinal Obs amp Vital Signs bbe D Maternity Nervous Status System History Ts E Mental Health Exclusion Drug Inter
102. mpletion of extensive notes This should however be restricted to the nature of the illness or injury and not replace or duplicate data fields elsewhere within the configuration Date and Time of Onset allows the clinician to enter the point at which the present complaint originated For ongoing or long standing concerns this should be the point at which that concern became severe enough to require ambulance intervention The Intended Destination fields open up drop down boxes so that the user can indicate which hospital they may be transferring the patient to The three drop down boxes begin with Division then to Hospital and finally to the Department where the patient may be conveyed By selecting an appropriate destination the system opens up the technical link between the hospital and the server so that the receiving hospital department can access the patient identifiable information If this drop down functionality is not used the receiving department will not be able to view the record until such time as the ambulance arrives History of Pisoni aa a l SA Presenting Condition Category Exami mw nation Major Presenting Condition Trauma Body Map Date amp Time of Onset Exclusion Contrain dication ear Intended Destination ESIA SE COyTin thes effective 4 3 1 Priority Incident South Western Ambulance Service NHS NHS Foundation Trust The clinician can enter the n
103. munity Care Services by reason of mental or other disability age or illness and maybe unable to take care of themselves or protect themselves against significant harm or exploitation Is Patient currently residing in care facility Police Incident Number Does Patient s family provide care at home Patient known as frequent caller Does Patient s care package require review This referral has been discussed with the Patient and or their Guardian NOK responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 9 18 It is important that the clinician review all data fields and provides as much information as possible either using drop downs Yes No or the Free Text fields which will expand to allow for maximum data capture Itis important that the referring clinician provide their contact details so that further information or clarification can be sourced as soon as possible 4 9 19 Once completed the Vulnerable Adult and Vulnerable Child referrals can be accessed and emailed directly to the Trust Safeguarding Team as previously described in the Referrals screen Priority Final Disposition Referrals Incident f Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Refusal Safety Net ting Safe guarding Right Care Air Ambul ance Log Attach ments gt Test Patient Risk Fact
104. n This opens up a separate data entry field for the capture of information relating to that Management gt Test Patient i Medical Assessment Priority Condition History of Condition Exami fas anea 6 CG13 Intraosseus Access nation Major Trauma Intra Venous Cannula Body Map Iv Incident Vital Signs Other Maps Status Exclusion History Contrain dication Arterial Tourniquet AT Secondary Survey Drug Inter vention Treatment Discharge Delete 7 resporishye OTIN nithed effective South Western Ambulance Service NHS 5 j a a e r a he NHS Foundation Trust 4 3 30 In order to allow the clinician to free hand draw a diagram or pictorial representation of the wound or injury etc a large free text drawing box is provided 4 3 31 The clinician clicks on Change and then uses the stylus provided to draw onto the screen the image they require 11 57 ss lest Patient ortivus lt lt iui Medical Assessment Priority Condition History of jen Condition Incident Eun nation Major Trauma Body Map Vital Signs Other Maps Status History Exclusion Contrain dication Secondary Survey Drug Inter vention Treatment Discharge responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 3 32 Other Maps provides the clinician with the opportunity to document in pictorial
105. n Belief Sexual Orientation NAS Foundation Trust 4 2 8 Everyone registered with the NHS in England and Wales has their own unique number This is provided in writing when initially registered with a GP practice The NHS Number helps healthcare staff to find and integrate health care records Each NHS Number is made up of 10 digits shown in a 3 3 4 format 4 2 9 As efforts to standardise electronic patient data increases and system integration becomes a reality the NHS Number will become ever more central to the management of patient identifiable data It is therefore vital that this information is captured where possible and entered onto the record 4 2 10 The NHS Number can be found on any correspondence that the patient may have from hospital or from their GP and is often included on repeat prescription documentation 4 2 11 Additional functionality has also been provided within the ePCR to search the NHS Spine and pull the relevant information into the ePCR This is achieved via a Patient Demographic Service button which brings up the screen below Once the information entered is validated the NHS Spine will then be searched and appropriate data collected Verify search parameters Patient Forename Test Searching If the NHS Number and Date of Birth fields are completed then no other fields are required If the NHS Number field is not completed Surname Date of Birth Gender and Postcode are required Pa
106. n arrow button simple Yes No functionality time fields and additional free text fields Cardiac Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Oihar ata i v Pacing BLS ILS ALS prior to ambulance arrival BLS ILS ALS prior to ambulance arrival by whom Pre cordial Thump y mime A e Pre cordial Thump Successful ew A Time Automated CPR device applied Automated CPR device Utilised responsive CTI nithed effective South Western Ambulance Service NHS 4 TEN NHS Foundation Trust 4 8 4 The Ventilation screen captures information relating to the use of BVM Bag Valve Mask and or any other Mechanical ventilator ortivus Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Oth oe Ito v CPR Ventilation Defibrillation ROSC Resuscitation Stopped Withheld CoD Pacing _ i coynnritted South Western Ambulance Service NHS NHS Foundation Trust 4 8 5 Priority Incident Primary Survey Vital Signs Status History Secondary Survey
107. n to enter details of any deviation from guidelines with regards medication 4 7 13 The clinician can select a drop down list of medications using the white finger symbol The clinician can then enter the Rationale for deviation or provide details of any exclusion or contraindication in free text format gt Test Patient a Suu Exclusion Contraindication lt lt Priority tered Pre Ambulance Exclusion Contraindication Formulary Adminis Incident tered Supplied Primary Survey Exclusion Contrain dication Rationale Vital Signs Status History Secondary Survey Treatment Discharge responsive com nithed effective 4 8 4 8 1 4 8 2 4 8 3 Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge South Western Ambulance Service NHS NHS Foundation Trust Primary Tab Treatment Cardiac Screen The Cardiac screen has a number of tertiary tabs which enable the clinician to capture details of any clinical intervention or treatment relating to cardiac events These include CPR Cardio Pulmonary Resuscitation Ventilation Defibrillation ROSC Return of Spontaneous Circulation Resuscitation Stopped Withheld CoD Confirmation of Death and Pacing The CPR screen enables the clinician to enter information relating to the management of a cardiac arrest This screen combines drop down lists accessed via the dow
108. nadian C Spine tool This will provide guidance to the clinician to support the decision making process General Cardi C Spine Assessm ovascular CSpineAssessment pi Respiratory I q Gastro intestinal Obs amp Gynae amp Maternity Nervous System Mental Health Exclusion Contrain SF ee dication responsive committed A Ee rt South Western Ambulance Service h z a gt NHS Foundation Trust 4 6 73 The clinician is directed through a series of questions each section dependant on the answers provided in the previous section The C Spine Assessment will support and document the decision making process prompting the clinician to immobilise the patient based on the Canadian C Spine rules The functionality also allows for the capture of additional information using the free text Comment field S gt lest Patient ae General Musculoskeletal Priority Cardi ovascular Incident f Respiratory gt ane Goa Simple Rear End RTC tess No Pathway type Patient ambulatory at any time L Yes No Change ey Gynae amp Patient has delayed onset of neck pain laes No lt gt Maternity Patient has absence of mid line C Spine tenderness P Yes a hea NO a 0 0 Nervous ANER T Status System Proceed to Neck Rotanon Delete History Survey intestinal Obs amp Comment Vital Signs Pathway status Muscu loskeletal Neck Rotation Mental Health Is the Patient able to actively rota
109. ngoing care plan S gt Test Patient Presenting E Medical Assessment Priority Condition History of Condition Incident Bunn nation Major Trauma n VAVE Seat Belt Worn Trapped Length of Time Oe Child Restraint Worn Ejected Vital Signs Other Maps E Exclusion History gonea Yeso a Do Yesa No dication Air Bag Deployed Secondary Survey a Drug Inter vention Treatment Discharge response i committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 3 38 The Motorcyclist tab captures data relevant to road traffic collisions involving motor cycles An additional free text field is available within the Motorcyclist field which expands as text is entered This supports the capture of additional information such as the condition of the road the weather at the time of incident the use of appropriate leathers or other protective wear and the nature or mechanism of the collision etc ortivus lest Patient Priority Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge AERLE Medical Assessment Condition History of Road Traffic Collisi Vehicle Occupar storcyclis Cyclist Pedestriar Other Condition Exami facie a WEG Helmet Worn Trauma fe WEUEON Helmet Removed Prior to Ambulance arrival Other Maps Estimated Impact Speed mph Exclusion Contrain dication
110. nitor A number of clinical decision tools are available within the configuration these utilise Checklists and scoring systems to aid the clinicians decision making The Wells Score for DVT Deep Vein Thrombosis is a nationally validated tool which assists in determining the risk of a DVT being present The tool is accessed via the Change button as below KERA South Western Ambulance Service h z KJ NHS Foundation Trust ortivus a Test Patient Be esata Cardiovascular Guide lt lt Priority Cardi ovascular Incident DVT Wells Score DEKO Active cancer Paralysis Recently bed ridden Localised tenderness Entire leg swollen Calf swelling Pitting odema Collateral DVT Alternative diagnosis Primary Gastro Survey intestinal Obs amp Gynae amp Change _ e Maternity Total Vital Signs Nervous Status System History A loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge 2 8 Once the Change button is clicked the Checklist opens The clinician is directed to ask specific questions or undertake specific assessments Each requires the clinician to input the result and once all have been completed to click the Ok button ortivus 5 Test Test 123 456 7890 DVT Wells Score Active cancer Paralysis Recently bed ridden Localised tenderness A Treatment ongoing within six months or Paralysis paresis or recent plaster Recently bed ridd
111. ns Status History Drug Inter vention Treatment Discharge Gastro Muscu South Western Ambulance Service NHS NHS Foundation Trust Primary Tab Secondary Survey General The General screen has a number of tertiary tabs which allow the clinician to enter information that relates to the more detailed assessment that is conducted once any life threatening observations have been concluded The Pain Assessment screen allows the clinician to enter a detailed assessment of the patients pain in terms of location whether it is referred to a separate body area whether it radiates from the main location to a point distal to that centre and whether there are any factors which help the patient relieve the pain or conversely anything that makes it worse lest Patient General General ovascular Character of pain Onset Date amp Time Free Text Respiratory intestinal Obs amp GUER a Radiated Pain Score Maternity Pain Score Pain Other Wong Baker Pain Vocalisatior Nervous 4 ea a Scale System Change loskeletal Referred lt PA Mental Health 0 0 Exclusion Fme Tat B Delete Contrain dication E bating or Remitting Yes Exacerbating or Remitting Free Text responsive committeg effective Ahi South Western Ambulance Service NHS NHS Foundation Trust 4 6 4 In order to enter site of the patient s pain the clinician first needs to click on t
112. nt These questions combine Yes No functionality and also capture duration and a final Free Text field to allow for the capture of data not entered elsewhere 4 6 69 Some questions such as worst headache ever neck stiffness may support identification of Meningitis or headache suggestive of cranial bleed and should be considered along with other findings when determining the final care plan ae lest Patient Priori General Nervous System Cardi ovascular Incident eeeh Was Patient s headache of sudden onset Headache Other Primary eHre Described as worst headache ever Survey intestinal 0 A Persistent worsening headache Gynae amp Fiala Worse on stooping straining or lying Nervous Status System Is neck stiffness present History Vital Signs Muscu loskeletal Does Patient have persistent vomiting Mental Health Salis Has Patient a diagnosis of migraine 7 Contrain vention dicati ds Does Patient have periods of dizziness Onset Time Has Patient suffered recent head trauma Drug Inter Treatment Duration hours Discharge Free Text responsive committed effective oe South Western Ambulance Service hz AJ NHS Foundation Trust 4 6 70 The Other screen enables the clinician to capture in a free text format data relating to the patient neurological status that is not captured elsewhere Test Patient Priority era Nervous System Cardi stroke A
113. nter vention Treatment Discharge General Cardi ovascular f Respiratory Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication Diarrhoea Constipation Bowel Sounds Abdominal Assessment 19 12 2014 12 31 O V Urinary Assessment connate E A South Western Ambulance Service h z j TEN Y NHS Foundation Trust 4 6 35 A generalised Abdominal Assessment can be located and recorded by clicking the New button ortivus ae General Priority Cardi Diarrhoea Constipation Bowel Sounds Abdominal Assessment Urinary Assessment ovascular Incident _ Respiratory Primary Survey Obs amp a Gynae amp Vital Signs y z Maternity Nervous Status System History Musai loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge connate South Western Ambulance Service NHS NHS Foundation Trust 4 6 36 Once the New button is clicked the clinician can enter details of a generalised abdominal assessment by clicking on the Yes No buttons Any additional information can be entered in the Free Text field ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular Respiratory Gastro intestinal Obs amp Gynae amp Maternity N
114. ntion Treatment Discharge resporishye committed effective poe da South Western Ambulance Service hz wn a NHS Foundation Trust 4 2 13 Details of the patients Genera Practitioner GP are entered within this screen they may be manually inputted or pulled from the NHS Spine on successful identification of the NHS Number ee Details Priority Patient Nok GP Consent Research Incident Times Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge oo nmitted South Western Ambulance Service NHS NHS Foundation Trust 4 2 14 Any patient assessment and subsequent treatment plan should be conducted with the Consent of the patient Additionally the transfer of that information to another health provider should be undertaken with the consent of the patient This does not however require that every patient counter sign to support the consent process 4 2 15 Should a patient refuse to allow the Trust to share their information the patient should be made aware that any subsequent care plan will be compromised The ePCR system will inhibit the electronic transfer of data if the No to consent is clicked 4 2 16 Should the patient not provide consent and the clinician determines that they do not have capacity to make that decision or believes that the Best Interests of the patient outweigh that decision a free text box will appear on
115. nts have been passed to accepting Clinician The Patient may remain physically in the care of the Ambulance crew Refusal Primary Safety Net Survey ting Safe Etue Patient Handover Accepting Clinician Name lamna Vital Signs Right Care Status Patient Handover Accepting Clinician Role Air Ambul History ance Patient Handover Accepting Clinician Signature Secondary Log Survey Drug Inter vention Hospital Patient Handover Time Physical Handover is the Time at which the Patient has been physically passed to accepting Clinician Treatment Has the physical handover been delayed following initial Clinical Handover EEE S South Western Ambulance Service NHS NHS Foundation Trust respDorsye Cori itteg effective South Western Ambulance Service NHS fs oh NHS Foundation Trust 4 9 10 The Referrals screen enables the clinician to utilise pre populated referral forms for onward management of the patient A series of options are provided once the large white down arrow is clicked In the example below the Main Record has been selected This record will then pre populate with information entered into the ePCR The output Record Referral will only collect data from the ePCR for data fields where data has been entered so any referral form is reliant on the clinician s completion of the ePCR For example if the Falls section within Secondary Survey has not been complet
116. o highlight the availability of and open a drop down list of multi select options Incident f Respiratory Sie Primary Survey Vital Signs Drug Inter vention Treatment Discharge 2 11 ortivus Priority Cardi ovascular Gastro intestinal Obs amp Gynae amp Maternity Nervous Status History f System Muscu loskeletal Mental Health Exclusion Contrain dication gt Test Patient fete Cardiovascular ECG Date amp Time Cardiac Rhythm p r a Other ECG ECG Date amp Time Does Patient have implantable cardiac defibri Cardiac Rhythm Yes g OK amp Cancel 12 18 amp Guide lt lt New Change g a a Ceo ua 0 0 Delete No Some patient assessments may be required to be undertaken on more than one occasion the patients vital signs for example may be entered on numerous occasions during the patient contact to capture trends or show improvement or deterioration Multiple assessments fields are available via the New button which open up the data entry points for each new set of data responsive committed effective 2 12 South Western Ambulance Service NHS NHS Foundation Trust To enter an additional data set the clinician simply clicks on New to open up a new assessment field Additionally once this data has been entered it can be changed or deleted as required using the Change and
117. ondary Survey Drug Inter vention Treatment Discharge coynnritted 4 4 4 4 1 4 4 2 4 4 3 Incident Primary Survey Status History Secondary Survey Drug Inter vention Treatment Discharge South Western Ambulance Service NHS NHS Foundation Trust Primary Tab Vital Signs Vital Signs tab allows the clinician to enter multiple patient vital signs where connected to Mobimed Vital Signs Monitoring equipment these some fields will be auto populated Additional information may be added to sets of observations or manual entry of observations when not using Mobimed Vital Signs Monitoring equipment may also be entered To enter a set of patient observations the clinician clicks on the New tab Should you wish to alter or change a set of observations the clinician highlights the set of observations by clicking on them then click Change Additionally to delete a set of observations the clinician highlights the set of observations by clicking on them then click Delete Test Patient Vital Signs EE E e E oOF o f Jo J oHoJ H4dJ J d J J f4 JTJS Js _ a Resp Rate Change Pulse BP Standing or Sitting or Laying ia eis Systolic BP 0 0 Diastolic BP Delete BP Left or Right SpO2 on air SpO2 on oxygen EtCO2 Blood Glucose Temperature Method of Capture PEFR 60 800I pm PEFR Patient s Norm 60 800I pm PEFR Unable Refused Vital Signs Fre
118. ont Secondary Log Would the Patient have received more appropriate care at a different time of day Survey Did you attempt to contact an ECP for further advice Drug Inter vention ee a Did the ePCR assist you in providing the Patient with the Right Care Treatment i Was the Directory of Services useful to you in providing the Right Care responsive CE TIFT ithe effective i South Western Ambulance Service h z NHS Foundation Trust 4 9 27 The Air Ambulance screen enables the Air Ambulance to capture data relevant to any mission this includes details to evidence any clear on scene A drop down list including Weather Patient Refusal to fly etc can be accessed by the black drop down arrow gt Test Patient E UGE Air Ambulance las Priority Disposition ei re Air Ambulance Clear On Scene Reason Referrals aa Incident f AA Air Ambulance Clear On Scene Reason Primary Safety Net Survey ting Safe Vital Signs a Right Care Status Air Ambul History ance Secondary Log Survey Attach ments Drug Inter vention Treatment responsive committed effective
119. or less g Pathway type VES TOS Other Maps Open or flail chest st Comment P hii NO atus Exclusi Crushed de gloved led limb History E Pathway status rushe gloved or mangled lim y dication Suspected pelvic fracture Yes No Suspected neck or back injury with paralysis Yes No More than one fractured proximal long bone Yes No Drug Inter F Amputated limb Yes No vention j Suspected open or depressed skull fracture Yes _j _No Treatment Comment Sustained systolic BP under 90 or absent radial pulses Yes No Secondary Survey Discharge 19 12 2014 11 55 0 OK Cancel responsive OTIN nithed effective South Western Ambulance Service NHS NHS Foundation Trust 4 3 25 The Body Map screens enable the user to annotate a body map either from a view of the Front of the patient or from a view of the Back of the patient This identifies the position on the body of a Burn Fracture Dislocation Amputation or Wound 4 3 26 The clinician clicks on the relevant button then on the body to show location This opens up a separate data entry field for the capture of information relating to that Injury Priority Incident Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge Presenting Condition History of Condition Exami nation Major Trauma Body Map Other Maps Exclusion Contrain dication es lest Patient Medical Assessment
120. ors Involved Safeguards put in place to protect the Patient Known views of Patient Carer Concerns shared with Referrer name Crew Pin number Contact number feSsporishve committed effective NHS Foundation Trust roi South Western Ambulance Service h z KJ 4 9 20 Should the clinician attend and need to document a Child Death the screen below captures data relating to the nature of the death via the black drop down arrow Free Text fields are then provided for any information which may be useful at the time or at a later date for any further review or investigation into the death Itis important that the clinician documents as much detail as possible to ensure that soft intelligence relating to the environment atmosphere attitude of those on scene is captured to assist in any future investigation should that be required Test Patient Final Priority Disposition Referrals Incident f me Where was the child at the time of the event or condition that lead to death eTusa Free Text Primary Safety Net Survey ting Vital Signs Please supply in detail the environment that the child was found Right Care Status Aw Ao Please describe any difficulties experienced when delivering care to the Patient History ance Please detail others present in the household Secondary Log Survey iiin ei a Name Change vention Relationship to Child Drug Inter Additional Comments
121. output forms This can be created and auto populated from data already entered to enable Falls Referrals TIA Clinic Referrals Safeguarding Referrals and other suitable clinical outputs which further enhance the patient outcome and patient experience 1 7 1 8 2 1 2 2 2 3 2 4 South Western Ambulance Service NHS NAS Foundation Trust The device also provides a platform for other uses supportive of the clinical environment The device incorporates a web browser enabling the clinician to view a selection of approved websites such as Toxbase Athens and NICE The device also holds a number of hard file documents such as JRCALC other national and local Clinical Guidelines Patient Group Directions and Operational Instructions The system can and will also enable access via web links to the Directory of Services Crews are often unaware of the options available to them to enhance the appropriateness of conveyance and this will greatly enhance the ability of SWASFT to build on its Right Care agenda increasing the appropriateness of conveyance and decreasing the numbers inappropriately conveyed to the emergency departments Clearly the benefits the system brings relate to enhancing the patient experience supporting the decision making process and opening up real opportunities for the transmission of data But equally important is the data that will be captured by SWASFT in relation to its operations Such data will enable r
122. oxicillin 500mg Amoxicillin 250mg in 5ml Aspirin 300mg TIA Pack Cetirizine 10mg Prequency Chloramphenicol 1 Batch number Chlorphengfhig 4mg Pack Search Supplied by Medication supplied by Crew x Cancel 4 7 10 Once the medication is selected other data fields for route of administration dosage and unit etc will pre populate These fields can be overridden and pre populate to support the clinician only Any medication where a dose range can be given will pre populate with the lowest dosage committed effective prom South Western Ambulance Service NHS NHS Foundation Trust 4 7 11 The clinician must complete the Supplied by section to comply with the legal requirement for all supplied medication to be authorised When not in signal the clinicians 8 digit pin number must be entered in the Medication supplied by Other field gt Test Patient Pharmaceuticals Aciclovir 800mg Aerochamber blue Unit Aerochamber and mask yellow tional C Additional Comments Aerochamber and mask orange Amoxicillin 250mg Amoxicillin 500mg Amoxicillin 250mg in 5ml Aspirin 300mg TIA Pack Cetirizine 10mg Supplied by Chloramphenicol 1 Medication supplied by Crew Chlorphenamine 4mg Pack Search amp Guidelines responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 7 12 The Exclusion Contraindication screen enables the clinicia
123. pe Muscu L Comment CSG Resuscitation Withheld eee uo uw atnway status Burn Inter Mor _ vention r ith Status Wound Resuscitation Withheld Time Delete Primary Survey Vital Signs History Care Hae Resuscitation Free Text Secondary morrhage Survey Control Expected Death Drug Inter Respiratory i vention SoU Date last Seen by GP Care Throm bolysis Valid DNAR ADRT TEP AND ein SS a Discharge risation LN 5 No Te I v responsive committed effective poy South Western Ambulance Service hz aye D NHS Foundation Trust 4 8 10 The Resuscitation box provides the clinician with a list of questions with Yes No answers any Yes would constitute a sufficient rationale to withhold resuscitation and this will be displayed as below gt lest Patient a i Priority Se Chrical pathways Cardiac Rastlecitation Incident Advanced Resuscitation Stop Resuscitation Airway primary Immobi ite Resuscitation Stop Decapitation L Yes No Survey Muscu Massive Cranial Cerebral destructio Yes j No j SAGHE Resuscitation Withheld Vital Si r i z ee Burn Inter Spaces calaaai es a ce a vention Decomposition Putrefaction Resuscitation ie i hat ES aa N Status Wound History Care SE Resuscitation Free Text Foetal Maceration ae a e Secondary morrhage Survey Control Incineration Delete __ Hypostasis Expected Death Rigormortis __ Withold
124. ply clicks on the down arrow to select from the list of options gt lest Patient General Respiratory 6 Guide lt lt Cardi ovascular 3 Is The Patient Breathless Respiratory Time Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication responsive committed effective re South Western Ambulance Service hz j r gt eh ae NHS Foundation Trust Re ta sae a 4 6 28 Similar to the Wells Deep Vein Thrombosis Tool the Wells PE tool assists in the risk assessment for the likely diagnosis of a Pulmonary Embolism In order to undertake the assessment the clinician selects Change the PE tool checklist will then be provided for completion ae General Priority a General Croup Assessment Modified Dyspnoea Scale Pulmonary Embolism Ovascular Incident DVT svmr gt wt 105 cs likely HF 100 Pat d Pre s DVT or PE Ae Hianancy 1 Survey intestinal Obs amp ER Gynae amp Vital Signs y Maternity Nervous Status System History Muscu loskeletal Mental Health Exclusion rug Inter Drug inia Contrain vention Bia dication Treatment Discharge cp nmitted PZA South Western Ambulance Service hz 2 TEN NHS Foundation Trust 4 6 29 The Clinician will be provided with the checklist as below the clinician simply answers the questions presented and clicks
125. provided Condition Incident Bunn Trauma _ Major Trauma Assessment Body Map i Vital Signs Pathway type Change Comment Status 2 Exclusion History F Pathway status eat lei ontrain dication 0 0 Secondary S Delete urvey Drug Inter vention Treatment Discharge TESKA Sie COMTI nithed effective South Western Ambulance Service NHS if ie NHS Foundation Trust 4 3 23 Should the clinician consider that the patient may activate the Wessex Trauma Triage Tool they should undertake the Major Trauma Assessment This provides a drop down checklist which supports the clinician in undertaking the Wessex Trauma Triage Tool and supports the clinician in making a decision as to the most appropriate receiving unit for the patient 4 3 24 This tool is a support for the clinician and does not remove the clinical responsibility nor does it determine the course of action to be followed By clicking Yes or No as appropriate the tool will generate an output based on the Wessex Trauma Triage Tool and suggest an outcome based on that tool ss lest Patient Ne Maior Trauma PE Priority Condition meam Clinical pathways History of Mechanism of injury E E E Condition Incident eres gt Does the Patient Fulfill Any of the Following Criteria nation Yes Sustained respiratory rate of under 10 or over 29 Major Trauma Asses anal SS Nena Body Map e Vital Signs GCS motor score of 4
126. questions be answered Yes the risk of serious aetiology without other indications is considered low Any additional information not captured elsewhere can be recorded within the Comment free text field gt lest Patient Anae Nervous System Cardi stroke i cual Sensory ILOC Gonvulsions Headache Other ovascular 2 Respiratory a Mente Pathway type a Change Obs amp Comment Gynae amp Posture Su ez Maternity Pathway status Mi asm pees Post longed standing a System a iiia laes Now Delete Muscu Provoking factors pain or medical procedure on a e AEAN syncope Prodromal symptoms sweating or feeling hot Yes No J eee ES OE U e Mental e DOE SA Health ee s Pathway type Ch Exclusion ange Contrain Comment 19 12 2014 12 45 seas gt dca Pathway status C Cee a ena ena J OK x Cancel 0 0 Delete Syncope Free Text responsive committed a South Western Ambulance Service h0 w PEN NHS Foundation Trust 4 6 66 The Convulsions screen enables the clinician to document findings in relation to any convulsion or seizure activity To access the assessment the clinician clicks on the New button ue General Priority Cardi Stroke TIA Cranial Nerves Visual Sensory TLOC Convulsions Headache Other ovascular Incident A Respiratory Primary Gastro Survey intestinal Obs amp S Gynae amp Vital Signs y Maternity Status History Mu
127. raised normal or lowered and a free text format field for the recording of specific details gt Test Patient N citi Cardiovascular Priority Cardi ovascular Incident Jugular Venous Pressure Respiratory Primary Gastro ETit Survey intestinal Obs amp Gynae amp Maternity Vital Signs Nervous Status System History Muscu loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 19 The Wells Score for Deep Vein Thrombosis is a clinical support tool to assist Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge in the determination of the likelihood of the patient suffering a DVT In order to access the tool the clinician simply clicks Change lest Patient ee Cardiovascular Cardi ovascular REGO Active cancer Paralysis Recently bed ridden Localised tenderness Entire leg swollen Calf swelling Pitting odema Collateral DVT Alternative diagnosis intestinal Obs amp Gynae amp Change _ Je Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication responsive committed DERA South Western Ambulance Service hz NHS Foundation Trust 4 6 20 Once the clinician clicks on Change
128. re Delete Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Oih olata D 4 responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 8 7 Once the RoSc screen is open the clinician uses the relevant time fields to capture RoSc Time and Time Lost ortivus Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation Othar miar v Ventilation DALEN ROSC Resuscitation Stopped Withheld CoD Pacing i Sve cp ri nitted South Western Ambulance Service NHS NHS Foundation Trust 4 8 8 The Resuscitation Stopped Withheld screen captures data relevant to the cessation of resuscitative efforts Most data fields are simple Yes No or Time capture fields 4 8 9 The Resuscitation Box allows the clinician to document information related to the requirement to withhold or continue resuscitation The clinician clicks on the New button to open this tool gt Test Patient Priority Cardiac DR Warnistion Garaa anii i ithhelc i Pacing Incident Advanced Airway ata Change Immobi ane A Resuscitation Stopped Time Pathway ty
129. re therefore very useful in any post incident review Priority Incident Primary Survey Vital Signs Status History Secondary Survey Drug Inter vention Discharge Cardiac Advanced Airway Immobi lisation Muscu loskeletal Burn Inter vention Wound Care Hae morrhage Control Respiratory Critical Care Throm bolysis Cathete risation D 4 S Test Patient 1st Intervention Attempted Ye 1st Intervention Successful Y 1st Location Name of Clinician Time of Intervention Indication Rationale 2nd Intervention Attempted Technique Equipment Used TESKA ISE committed emectve South Western Ambulance Service NHS NHS Foundation Trust 4 8 45 Should the clinician have received additional education in the provision of Finger Thoracostomy and have been assessed and deemed competent in this skill the Finger Thoracostomy screen enables the clinician to document the use of this procedure 4 8 46 The Thorocostomy Free Text field should be sued to document the Priority Incident Primary Survey Vital Signs f Status History Secondary Survey Drug Inter vention Discharge Rational Indications Technique used and any Complications experienced This information assist in understanding the thought processes and decision making processes and are therefore very useful in any post incident review gt Test Patient Cardia
130. red in free text format within the Mental Health Condition Free Text field 4 6 88 If the patient is being Restrained details of the method used and rationale should be recorded within the appropriate Free Text field 4 6 89 The Suicide and Self Harm Risk Assessment can be accessed by clicking the Change button lest Patient E eme Mental Health Priority re Does patient have clinical diagnosis of Mental Health Condition Suicide amp Self Harm Risk Assessment ovascular m Gender Below 19 Above 45 Depression Self harm Alchohol Drugs Incident ai a a Nseicivels a Mental Health Condition Free Text Rational Absent Relations Organised Loneliness Determination Total Primary i Gastro Survey WGE Is Patient being conveyed under Mental Health Act Obs amp Ye Gynae i n eee A oma Vital Signs Maternity If Yes under which Section of the MHA are they being conveyed Nervous f ome Status System Is Patient being restrained Muscu loskeletal ee Ce Menai Free Text Health History Ex i Drug Inter pe If Yes is Patient being conveyed to Place of Safety vention dication itt o Treatment Discharge responsive committed effective Mere South Western Ambulance Service NHS NHS Foundation Trust 4 6 90 Once opened the Suicide and Self Harm Risk Assessment can be used to calculate the relative risk of suicide or self harm The clinician answers the questions as below and clicks the
131. relevant buttons Once all questions are answered and Ok is clicked the relative risk is displayed ortivus 5 test test 123 456 7890 Mental Health Priority Vital Signs Status History Drug Inter vention Treatment Discharge ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Guide lt lt i Suicide amp Self Harm Risk Assessment Gender 0 mpn Male J Self harm Previous attempts at self harm Evidence of excess alchohol illicit drug use Rational thinking absent Organised Organised or serious self harm No close reliable family job or active R no General Cardi ovascular Gastro intestinal Obs amp Gynae amp Maternity Nervous System Muscu loskeletal Mental Health Exclusion Contrain dication Below 19 Is age lt 19 years me mian Alchohol Drugs Depression Hopelessness Relations Separated Divorced Widowed em Is age gt 45 years No Female No Yes Yes Rational Absent No No No No mad Loneliness Yes Yes Yes Yes Determination Determined to repeat or ambivalent 0 No J OK amp Cancel religious affiliation afl mian Yes Yes Yes gt test test 123 456 7890 Mental Health 4 Suicide amp Self Harm Risk Assessment Gender Below 19 Above 45 Depression Self harm Alchohol Drugs 1 1
132. responsive Comm itteg effective South Western Ambulance Service NHS ifr NHS Foundation Trust 4 3 39 The Cyclist tab captures data relevant to road traffic collisions involving bicycles An additional free text field is available within the Cyclist field which expands as text is entered This supports the capture of additional information such as the condition of the road the weather at the time of incident and the nature or mechanism of the collision etc gt lest Patient og lt lt Priority Condition History of FR oad Traffic Collision n Vehicle Occupant Vo orcy list ajsa sjan 5 X Condition Incident Bunn nation Major Trauma SEE Estimated Impact Speed mph Vital Signs Status 3 Exclusion History Contrain dication Secondary Survey Drug Inter vention Treatment Discharge responsive committed effective South Western Ambulance Service NHS ifr DANA NHS Foundation Trust 4 3 40 The Pedestrian tab captures data relevant to road traffic collisions involving pedestrians An additional free text field is available within the Pedestrian field which expands as text is entered This supports the capture of additional information such as the weather at the time of incident and the nature or mechanism of the collision etc as lest Patient B iu Medical Assessment Priority Condition History of ad Traffic Collis kaaa arre 5 Hs Condition Incident
133. responsive committed PZA South Western Ambulance Service h z w TN NHS Foundation Trust 4 6 51 Should the clinician consider that the patient may have suffered a TIA the TIA screen allows for data entry to support a structured TIA Examination and also to capture the ABCD2 score by clicking on the appropriate New button G Priority Jer eral dai Stroke TIA Cranial Ner ves Visual Sensory LOC Convulsions Headache Other ovascular f Incident Respiratory Ia Primary Gastro Survey intestinal Obs amp ee Gynae amp Vital Signs y Maternity Status History Muscu loskeletal Mental Health Exclusion Drug Inter z g Contrain vention Ass dication Treatment Discharge connate Bree South Western Ambulance Service NHS NHS Foundation Trust 4 6 52 The TIA Examination screen opens up a short series of questions to support the evaluation of TIA The clinician selects Yes or No as appropriate and the clicks Ok oe General Priority Cardi Stroke AMA Cranial Nerves Visual Sensory TLOC Convulsions Headache Other ovascular f Incident Respiratory _ Primary Gastro Survey intestinal Obs amp Has Patient s symptoms fully re Gynae amp WE ane eee SS Vital Signs h Maternity Status History Muscu TARE ABCD SS Mental Health ae Exclusion ee 19 12 2014 12 40 w Drug Inter Bp Contrain i dication PESIIN A Treatment Discharge responsive
134. rust 3 17 The Settings function within the Control Panel allows the user to access functions such as synchronisation of settings between the EUD and the Server This screen also allows the user to Send Eventlogs this captures all data over a period of time and allows Ortivus to then analyse that data This is very important if the device fails or any operation does not work as expected The user must click on Send Eventlogs as soon as possible after the identification of any fault ortivus 14 07 C Control Panel 3 18 The New Incident and Open Incident buttons on the man menu screen enable the user to create an incident with multiple casualties and to manage those patients by creating ePCRs for these patients and to then manage the ambulance resources and allocation of patients to those resources ortivus 14 07 Filter From 18 08 2014 15 07 Update bama To Intended Destination Hospital 20 08 2014 15 07 en Showing 0 entries Login to see incidents Time Created State Incident name Incident description Created by User Incident leader Created by Unit respDorsive Cori litte effective poe South Western Ambulance Service hz r SN y NHS Foundation Trust 4 Electronic Patient Clinical Record 4 1 Primary Tab Priority 4 1 1 The Priority tab does not currently provide any functionality this is incorporated into future developments to support the clinician
135. s necessary ortivus Test Patient 13 19 HUG Refusal Priority Disposition Patient Declaration Attendant signature Despite advice given I have declined assessment treatment transport The associated risks have been explained to me should my symptoms remain or deteriorate Patient Signature Referrals Incident Refusal Primary Safety Net Survey ting Safe Vital Signs 944 ding Right Care ee Air Ambul istory ann Sign Secondary Log Witness Name Survey Attach ments Witness Relationship to Incident Drug Inter vention y aw Treatment responsive committed effective South Western Ambulance Service NHS fs oh NHS Foundation Trust 4 9 14 The increasing management of patients outside the Emergency Department requires the clinician to appropriately manage any deterioration and to provide appropriate Safety Netting This screen captures full details of the Advice Provided along with details of any onward referral 4 9 15 Should the patient have accessed 999 via a Care Line service it is important that they are notified of the outcome so that they can ensure that the service they provide is continued or temporarily halted as required 4 9 16 No copy of the ePCR should be routinely provided however the clinician should ensure that the appropriate Health Care Advice Leaflet is provided Test Patient E UO Safety Netting Priority Disposition Advi
136. sai loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge oo rier Lil tarer South Western Ambulance Service hz a S NHS Foundation Trust 4 6 67 The Convulsions assessment enables the clinician to enter details relating to the duration of any convulsion via the clock symbol buttons Additional Free Text fields are also provided to capture data not collected elsewhere gt lest Patient R Nervous System Guida Cardi N F A i N ac Act alalvala LOC farr ho Other ovascular Incident i Respiratory annie Duration From i Change Primary Gastro Survey intestinal Duration To Previous Febrile Convulsion Obs amp a Number in last 24 hours bene ae a Wel Post Ictal Symptoms Febrile Convulsion Free Text a A asise TORN Symptoms Free Tex Number in last 24 hours tatus System l History VIT Febrile Convulsion Vital Signs Delete Post Ictal Symptoms EEO Previous Febrile Convulsion Mental i WE Febrile Convulsion Free Text Post Ictal Symptoms Free Text Exclusion Contrain dication Time Drug Inter vention 19 12 2014 12 46 Treatment Discharge responsive committed South Western Ambulance Service NHS ei ean NHS Foundation Trust 4 6 68 Should the clinician be called to a patient presenting with a Headache various fields are provide to assist the clinician in undertaking a structured assessme
137. se Rate Grimace or Response to Stimulation Activity or Muscle Tone Respiration Total Nervous i Muscu loskeletal i 19 12 2014 12 37 t Mental Exclusion N Ox Qoe Res Contrain Delete dication i responsive committed sos South Western Ambulance Service h z A NHS Foundation Trust 4 6 47 In order to enter details of the APGAR score the clinician clicks the New button and the following screen will appear The clinician answers all the questions by clicking on the appropriate buttons the total APGAR score will be provided once the Ok button is clicked gt lest Patient Priority AEA Obs amp Gynae and Maternity Guide Cak Obs amp Gynae Maternity Incident f APGAR Prima Sune Appearance Pulse Rate Grimace or Response to Stimulation Activity or Muscle Tone 0 Blue or pale all over 0 Absent 0 No response to stimulation 0 None Blue at extremities Body pink lt 100 Grimace feeble cry when Some flexion le anata acrocyanosis a stimulated Vital Signs Status gt 100 Flexed arms and legs that resist ies No cyanosis Body and Leal a Cry or pull away when niang opments eg History A wean extremities pink mcan stimulated d Respiration i Absent 0 Drug Inter d 1 Weak irregular gasping vention E 2 Strong lusty cry Treatment Discharge responsive committed South Western Ambulance Service NHS NHS Foundation Trust 4 6 48 The
138. sessment can be accessed by clicking the New button Additionally if the patient is catheterised it is important to enter the Date of Last Catheter Change this may be important when considering any retention and any requirement to organise a catheter change via ECP or district nurse etc ortivus Priority Cardi ovascular Incident Respiratory Primary Gastro Survey intestinal Obs amp Gynae amp Maternity Vital Signs Nervous Status System History Mao loskeletal Mental Health Exclusion Contrain dication Drug Inter vention Treatment Discharge erie Gastro intestinal Guides gt lest Patient 12 33 te Change Is there evidence of urinary retention Do they have pain on passing urine Is there evidence of blood in urine i Nai Has frequency of urination increased o0 Is urine cloudy Delete Is patient catheterised Hesitancy Urgency Poor Flow Dribbling Nocturia Supra pubic tenderness Date of Last Catheter Change bm p Urinalysis Positive For resporishye committed effective poe EN South Western Ambulance Service NHS NHS Foundation Trust ortivus Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge General Cardi ovascular f Respiratory am Obs amp Gynae amp Maternity Nervous System Muscu loskeletal
139. t Leg Drug Inter Contrain Sensory Power vention Left Leg Right Arm Vital Signs dication Bicep Treatment Tricep Patella Discharge Achilles Planter r i responsive committed effective South Western Ambulance Service NHS NHS Foundation Trust 4 6 63 Should the clinician be called to a patient with suspected TLoC Transient Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Cardi ovascular Gastro Loss of Consciousness the TLoC screen assists in providing a structured assessment following guidance from NICE The TLoC and Syncope assessments can be accessed by clicking the relevant New button gt Test Patient Cuac Nervous System Guidas _ Convulsions _ Headache Other Respiratory intestinal Pathway type Change Obs amp Comment Gynae amp lt gt Maternity Pathway status Mmmm sed 0 0 Nervous System Delete Muscu loskeletal Syncope Mental zA Health Pathway type Change Exclusion Contrain Comment lt D dicate Pathway status Vasas ai 0 0 Delete Syncope Free Text South Western Ambulance Service NHS NHS Foundation Trust 4 6 64 The clinician will be provided with a number of questions which support them Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment
140. te their neck to 45 atoms Exclusion degrees left and right tes Drug Inter 5 Contrain aS is vention a Immobilise patient dication un Treatment Comment Time 19 12 2014 12 48 7 Q x Q cancel Discharge responsive committed A Ee South Western Ambulance Service NHS NHS Foundation Trust 4 6 74 A general musculo skeletal assessment can be accessed via the Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Assessment tab To access the data fields the clinician clicks on the New button General Cardi C Spine Assessment Lower leg Assessment Soft Tissue Assessment Falls ovascular Respiratory I Gastro intestinal Obs amp Gynae amp Maternity Nervous System Mental Health Exclusion Contrain dication cp rin Lil South Western Ambulance Service NHS NHS Foundation Trust METER 4 6 75 The clinician can select the affected area s from a multi select Affected Area field by clicking on the white finger symbol Additional information can then be recorded detailing the Sensory and Circulatory impact of the injury along with an assessment of the Range of Movement 4 6 76 An additional Assessment Free Text field is also provided to allow for the capture of any data not entered elsewhere 19 12 2014 12 49 wor MoA responsive committed effective Se South Western Ambul
141. the following checklist appears the clinician then answers the questions as presented Once all ten questions have been answered the clinician clicks OK and the screen will identify the likelihood of a DVT being present The clinician must then make a determination based on this and other findings to provide a clinical outcome and determine the most appropriate course of action commi aC 5 South Western Ambulance Service h z 4 NHS Foundation Trust 4 6 21 The Respiratory screens allow the clinician to undertake a thorough assessment of the patients respiratory function 4 6 22 The first tab captures details of the General assessment this may be required to be undertaken on more than one occasion for example prior to treatment and after treatment The clinician simply clicks on New to undertake a new general assessment 4 6 23 An additional Free Text field is available should further clinical information be available that is relevant to the patients respiratory function Test Patient Priority eae Respiratory Cardi ovascular Incident Respiratory ene ce Is patient able to talk in full sentences Change Survey WU Is patient short of breath at rest Obs amp BS gt G Is patient short of breath on exertion eam ma ynae amp 0 0 LEGUE Is Orthopnoea present Nervous Status System JECHA V Is there evidence of respiratory recession loskeletal Haemoptysis Mental Health sealne A Colo
142. tient Surname Patient MAS ND 123 456 789 Completion of the rest of the fields will help improve search results Date of Birth These following fields may contain a wildcard which is indicated by an asterisk The first two characters must be present with the following immediately Gender afterwards For example Patient Postcode First Name Valid example Sarah Wildcard example Sa Surname Valid example Sten Wildcard example St Post Code Valid example gt SN25 4YA Wildcard example SN A single space is required between the 2 sections of the postcode South Western Ambulance Service NHS E i Bie aa Cumme j effectve g South Western Ambulance Service NHS NHS Foundation Trust 4 2 12 NoK or Next of Kin information is entered into this page it is important that a mobile or other contact number is entered if the next of kin is not accompanying the patient This will enable the hospital to make contact should they require any additional information which is currently not entered or to discuss ongoing plans for the care of the patient ortivus gt lest Patient 11 46 ae artic Patient 6 Guide lt lt Priority Patient eee NoK Primary Contact Times Primary NoK Pri Contact N Survey any j Vital Signs NoK Primary Contact Relationship y _ Status NoK Primary Contact Informed History Details of School Secondary Survey Drug Inter ve
143. tion of Impact iieii Exclusion a ee ae ee ae Contrain dication Position of Patient Damaged Area Mechanism of Injury y E Vv es x cancel Delete 7 responsive committed 5 A South Western Ambulance Service NHS NHS Foundation Trust 4 3 35 The functionality relating to placement of pictorial information as described previously relating to a 5 Seat Car is also duplicated on a 7 Seat Car 15 Seat Minibus and Lorry S gt Test Patient el Medical Assessment Priority Condition History of Roe Condition Incident f z Exami nation Major Trauma i ton of Pate Pol Vital Signs DA Status E FA History Contrain dication Secondary Survey Drug Inter vention Treatment Discharge Delete 7 responsive committed South Western Ambulance Service NHS if NHS Foundation Trust 4 3 36 The Vehicle Occupant tab allows the clinician to enter data relating to a patient who has been subjected to an injury whilst in a vehicle Information relating to Head Restraint Seat Belts and Estimated Impact Speed etc are all important to convey a picture to the receiving clinician Estimated Impact Speed is the combined speed at point of impact for incidents involving two vehicles 4 3 37 Free text field is provided should details such as the make and model of vehicle condition of road weather at time of incident etc be relevant to any o
144. troke TIA Cranial Nerves Visai Sensoy TLOC Convulsions Headache Other cp rin Lil fry South Western Ambulance Service h z KJ qe rs A l NHS Foundation Trust 4 6 58 Details of the Visual assessment can be entered using the appropriate buttons as below The size of the pupil can be entered by clicking on the down arrow and selecting the appropriate size in mm 4 6 59 Any additional details such as impairment of visual fields or presence of hyphema blood in the eye etc can be captured using the Visual Free Text field provided gt Test Patient A Nervous S m Guide SS Priority General yste Cardi i V Visual Se Convulsions Headache Other ovascular Incident f Primary Gastro Does Patient have Survey UGUA Does Patient have Does Patient have impaired vision Left Obs amp a k Pupil Assessment anisina amnia ee Vital Signs ynan Does Patient have impaired vision Right g WEA Pupil Assessment Nervous Status System History Nitta Pupils Right Size Meee Visual Field Asses Pupils Left Size Delete c No Sluggish p Mental Pupil Assessment Reaction Right Health Visual Free Text p g Exclusion Contrain dication Drug Inter vention Treatment Discharge responsive committed pri South Western Ambulance Service h z 125 NHS Foundation Trust 4 6 60 The clinician can enter details of an assessment of the patients Sensory status by clicking the N
145. ur of Sputum STC Is Patient Smoker dication Ye s No cel Vital Signs Is patient using accessory muscles Delete Does patient have productive cough Drug Inter vention Treatment Discharge ESKA Shy committed effective poe EN South Western Ambulance Service NHS NHS Foundation Trust 4 6 24 Once New within General assessment is selected the screen appears as below allowing the clinician to record details of the assessment T General Priority carai General Croup Assessm lt ovascular Incident a AR Primary Gastro Survey intestinal Obs amp 5 Gynae amp Vital Signs y i Maternity Nervous Status System History Muscu loskeletal Mental Health patient nave proc Svatiya Colour of Sputum Contrain vention i i m a n I a pan Ddi SSS ae T Treatment MERASA 3 edie SS eD Drug Inter South Western Ambulance Service NHS NHS Foundation Trust 4 6 25 Should the clinician be concerned that the patient may be suffering from Priority Incident Primary Survey Vital Signs Status History Drug Inter vention Treatment Discharge Cardi Croup a determination of severity is essential to the decision making process particularly with regards onward care planning The Modified Tausig Croup score is an effective Croup Assessment tool supported by JRCALC In order to undertake the Croup Assessment the clinician clicks on Chan
146. use in both roles ortivus oe Test Patient a __ Immobilisation Priority Cardiac Vacuum Mattress Vacuum Splint Incident AAGA Cervical Collar Pelvic Splint Airway Immobi Primary lisation Survey Muscu loskeletal Vital Signs g Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter Respiratory ven Critical Care Throm bolysis Cathete Discharge risation Oihar Ito pee Yv responsive committed PZA South Western Ambulance Service hZ TEN NHS Foundation Trust 4 8 23 The Vacuum Mattress screen simply captures its use and the time the patient was immobilised ortivus yO Priority Cardiac Cervical Collar Pelvic Splint Rescure Board Scoop Stretcher Incident A Vacuum Mattress Vacuum Splint Traction Splint Extrication Other Airway Primary Survey Muscu loskeletal Vital Signs Burn Inter vention Status Wound History Care Hae Secondary morrhage Survey Control Drug Inter Resp renti iota a Critical Care Throm bolysis Cathete Discharge risation Othar Letea v Sve cp ru nitted PZA South Western Ambulance Service hz i TEN Y NHS Foundation Trust 4 8 24 The Vacuum Splint screen allows for the capture of multiple Vacuum Splints in order to access data fields the clinician clicks the New button ortivus a Priority Cardiac Cervical Collar Pelvic Splint Rescure Board Scoop
147. wider functionality 2 6 South Western Ambulance Service NHS NHS Foundation Trust Various mechanisms are used to assist the clinician in the provision of Data Entry Many fields are captured using simple Yes No type buttons This is supportive of the clinician and enables quick data entry it is also hugely beneficial in terms of data analysis Free text on paper records is notoriously difficult to analyse but data fields with pre defined definition can be used with great effect to appreciate trends over time and assist the trust in researching pre hospital care to improve patient outcomes Drop Down lists are also provided to support the clinical record keeping where the answers to a question may be variable The presence of a drop down list is indicated by the drop down black arrow ortivus 5 Test Test 123 456 7890 Priority Incident f Vital Signs Status History Secondary Survey Drug Inter vention Treatment Discharge 2 1 Presenting Condition History of Mechanism of injury Has ATMIST been provided Condition A dii Major Trauma Exami Ti ATMIST vided Site Vehicle incident ime pro Major Trauma Fall less than 2m Fall more than 2m Body Map Shooting and weapon Other Maps Stabbing and weapon Exclusion eee Blast dication T Burn Skeletal Organ Vessel destruction Blow s Amputation partial Amputation total Other g CB ePR vV Messages Lyf Mo
148. wn menu by clicking the down arrow and then selects the Number Applied and the relevant Time Applied This is vital should the appropriate referral for removal or after care be required ortivus Test Patient Wound Care Irrigated Dressing Applied Time Yes Local Anaesthetic Applied Dressing Applied Location Yes Nerve Block Wound Closure Yes Nerve Block Free Text Number Applied Dressing Applied Time Applied Dressing Applied Free Text Suture Size Suture Free Text 19 12 2014 13 11 Vv OK Q Cancel peo South Western Ambulance Service h z 4J NHS Foundation Trust 4 8 39 Should the clinician be managing any major bleed the Haemorrhage Control screen allows the clinician to document Arterial Tourniquet use including Time Applied and Time Removed The Tourniquet may be removed after the application of Pressure Dressings should this then manage the Haemorrhage sufficiently 4 8 40 The use Pressure Dressings and Haemostatic Gauze is also recorded along with the Number Applied and Time of application S Test Patient e Haemorrhage Control Priority n E Arterial Tourniquet Haemostatic Gauze an eee RightArm __ leftAm Right Upper Leg i Airway n L Haemostatic Gauze Number Applied amo oE ee OE AS A Pp di P Tourniquet Time Applied Survey Muscu loskeletal Tourniquet Time Removed Burn Inter vention Status Wound History Care Hae Pressure Dressing
149. y for the administration gt Test Patient Pharmaceuticals Adrenaline 1 100 000 a Adrenaline 1 10 000 Cardiac Arrest Adrenaline 1 10 000 Post ROSC Adrenaline 1 1 000 Amethocaine 0 5 Amiodarone 300mg Amiodarone 300mg in 250ml glucose 5 Atropine 1mg in 5ml 200micrograms per ml Atropine 1mg in 5ml CBRNE Guidelines Frequency Amount Destroyed Batch Number responsive committed effective A Ee f5 EN J South Western Ambulance Service NHS gt gt i HNA NHS Foundation Trust 4 7 8 Should the clinician be supplying rather than administering any medication the supply of multiple medications can be captured by clicking on the New button for each medication Supplied by the ambulance clinician Adminis fF Priority tered Pre Ambulance PA Adminis Incident tered Primary Survey Exclusion Contrain dication Vital Signs Status History Secondary Survey Treatment Discharge cojnritted South Western Ambulance Service NHS ifr NHS Foundation Trust 4 7 9 The clinician can either scroll down the alphabetical list of ambulance medications or enter the drug or partial name in the Search field gt Test Patient Pharmaceuticals Aciclovir 800mg _ Administration Aerochamber blue Amounj4upplied Aerochamber and mask yellow Aerochamber and mask orange Unit Amoxicillin 250mg Additional Comments Am
150. y medications that the patient has taken prior to ambulance arrival This may be as a result of the Patient Administered their own Medication in free text format or as a result of a Health Care Professional Administered Medication in free text format This would include over the counter medications alongside prescribed medications such as GTN Test Patient s Adminis Administered Pre Ambulance Priority tered Pre Ambulance Patient Administered their own Medication Free Text Adminis Incident tered ime Supplied Primary Survey SOWA Patient s Own Medication Dosage Contrain dication Vital Signs Health Care Professional Administered Medication Free Text Status Time History Secondary HCP Medication Dosage Survey Treatment Discharge TESKA Sie 1 committed effective NHS Foundation Trust South Western Ambulance Service NHS 4 7 3 The administration of multiple medications can be captured by clicking on the New button for each medication administered by the ambulance clinician Adminis Priority tered Pre Ambulance Incident Supplied Primary Survey Exclusion Contrain dication Vital Signs Status History Secondary Survey Treatment Discharge cojnritted South Western Ambulance Service NHS NHS Foundation Trust 4 7 4 The clinician can either scroll down the alphabetical list of ambulance medications or enter the drug or partial name in the Search field gt Test

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